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FREEPORT MEDICAL SUPPLY INC.
CH02151BD Sun River Health, Inc.
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Covered Entity Details
Entity Name
Sun River Health, Inc.
Subdivision Name
Harmony Healthcare Long Island at Roosevelt High School
Type
HRSA-Funded Health Center
340B ID
CH02151BD
Entity Address
1 WAGNER AVE
104
ROOSEVELT, NY 11575-1153
Grant Number
H80CS00313
Participating Start Date
4/1/2016
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
FREEPORT MEDICAL SUPPLY INC.
Pharmacy Address
D/B/A XTRA CARE PHARMACY
75 S MAIN ST
FREEPORT, NY 11520-3841
Pharmacy Comments
Contract Details
Approval Date
10/9/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Allison Dubois-Adach, COO
(914) 734-8503
Contract Pharmacy Representative
Xtracare Pharmacy
Chuck Madu, Owner
(516) 208-7432
Signed By Date
10/9/2017
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