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NOBLE HEALTH SERVICES INC.
DSH330224 HealthAlliance Hospital Marys Avenue Campus
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Covered Entity Details
Entity Name
HealthAlliance Hospital Marys Avenue Campus
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330224
Entity Address
396 Broadway
KINGSTON, NY 12401
Medicare Provider Number
330224
Participating Start Date
7/1/2016
Last Recertification Date
9/14/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
NOBLE HEALTH SERVICES INC.
Pharmacy Address
6040 TARBELL ROAD
SYRACUSE, NY 13206
Pharmacy Comments
Contract Details
Approval Date
10/14/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia Gavis, Chief Financial Officer
(845) 943-6024
Contract Pharmacy Representative
Debbi Barber, Director of PBM Relations
(315) 287-3600 Ext: 2423
Signed By Date
10/14/2016
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