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MEDFORD COMPOUNDING AND SPECIALTY PHARMA
CH02151BL Sun River Health, Inc.
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Covered Entity Details
Entity Name
Sun River Health, Inc.
Subdivision Name
LISH at Central Islip
Type
HRSA-Funded Health Center
340B ID
CH02151BL
Entity Address
159 Carleton Avenue
Central Islip, NY 11722
Grant Number
H80CS00313
Participating Start Date
1/1/2017
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
MEDFORD COMPOUNDING AND SPECIALTY PHARMA
Pharmacy Address
2612 ROUTE 112
MEDFORD, NY 11763-2551
Pharmacy Comments
Contract Details
Approval Date
1/13/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/13/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Allison Dubois-Adach, COO
(914) 734-8503
Contract Pharmacy Representative
Medford Chemists Inc
Crystal Koller, Vice President, Finance & Operations
(631) 475-1171
Signed By Date
1/13/2017
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