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AMERITA, INC.
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
AMERITA, INC.
Pharmacy Address
10204 WERCH DR.
UNIT 301
WOODRIDGE, IL 60517-2537
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES WEIS, EXECUTIVE VP & CFO
(773) 257-6642
Contract Pharmacy Representative
Amerita, Inc
Gaston Bernstein, VP, Contracting
(773) 229-9300
Signed By Date
10/16/2017
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