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31ST & 3RD PHARMACY INC
HV021430 CUMBERLAND DIAGNOSTIC & TREATMENT CENTER
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Covered Entity Details
Entity Name
CUMBERLAND DIAGNOSTIC & TREATMENT CENTER
Subdivision Name
Type
Ryan White Part C
340B ID
HV021430
Entity Address
100 NORTH PORTLAND AVE.
BROOKLYN, NY 11205
Grant Number
H76HA00023
Participating Start Date
4/1/1998
Last Recertification Date
2/22/2018
Entity Termination Date
10/1/2018
Pharmacy Details
Pharmacy Name
31ST & 3RD PHARMACY INC
Pharmacy Address
D/B/A AVITA PHARMACY 1063
1860 WALT WHITMAN RD STE 700
MELVILLE, NY 11747
Pharmacy Comments
Contract Details
Approval Date
4/4/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul Albertson, Vice President
(212) 748-2256
Contract Pharmacy Representative
Paramount SPecialty
Al DosSantos, Founding Principle
(631) 815-5776
Signed By Date
4/4/2018
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