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LIVONIA PHARMACY INC
FQHCLA334U 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
East New York Diagnostic and Treatment Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA334U
Entity Address
2094 Pitkin Ave
Brooklyn, NY 11207-3509
Grant Number
LALCS00169
Participating Start Date
7/1/2015
Last Recertification Date
2/22/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
LIVONIA PHARMACY INC
Pharmacy Address
625A LIVONIA AVE
BROOKLYN, NY 11207
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul Albertson, Vice President
(212) 748-2256
Contract Pharmacy Representative
Livonia Pharmacy Inc
Imran Siddiqui, Owner
(718) 484-8100
Signed By Date
10/12/2017
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