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KINGS THIRD AVE PHARMACY
DSH330214 NYU Langone Hospitals
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Covered Entity Details
Entity Name
NYU Langone Hospitals
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330214
Entity Address
550 FIRST AVENUE
NEW YORK, NY 10016
Medicare Provider Number
330214
Participating Start Date
1/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
KINGS THIRD AVE PHARMACY
Pharmacy Address
DBA: KINGS PHARMACY
1619 3RD AVE
NEW YORK, NY 10128-3459
Pharmacy Comments
Contract Details
Approval Date
4/23/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/23/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Burke, Corporate Chief Financial Officer
(212) 263-3092
Contract Pharmacy Representative
Promesa, Inc.
Dimitry Vagman, Supervising Pharmacist
(718) 230-3535
Signed By Date
4/23/2016
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