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PINEBROOK RX INC.
FQHCLA334AD 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
Segundo Ruiz Belvis Diagnostic and Treatment Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA334AD
Entity Address
545 E 142nd St
Bronx, NY 10454-2110
Grant Number
LALCS00169
Participating Start Date
7/1/2015
Last Recertification Date
2/8/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
PINEBROOK RX INC.
Pharmacy Address
DBA: PINEBROOK PHARMACY
1183 JEROME AVE
BRONX, NY 10452
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
Pinebrook Rx
Ravi Mamidela, Owner
(718) 992-8182
Signed By Date
10/12/2017
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