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MEDILANE PHARMACY CORP
FQHCLA334 NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
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Covered Entity Details
Entity Name
NEW YORK CITY HEALTH AND HOSPITALS CORPORATION
Subdivision Name
Washington Heights
Type
Health Center Program Look-Alike
340B ID
FQHCLA334
Entity Address
600 W 168th St
New York, NY 10032-3702
Grant Number
LALCS00169
Participating Start Date
7/1/2015
Last Recertification Date
1/31/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
MEDILANE PHARMACY CORP
Pharmacy Address
204 CLINTON STREET
NEW YORK, NY 10002
Pharmacy Comments
Contract Details
Approval Date
7/19/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Antonio Martin, Ececutive Vice President & Chief Operating Officier
(212) 788-3479
Contract Pharmacy Representative
Medilane Pharmacy Corp
Miriam Fung, Pharmacy Manager
(212) 571-2888
Signed By Date
7/19/2016
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