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475 NEW LOTS AVENUE PHARMACY INC
DSH330233 BROOKDALE HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BROOKDALE HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330233
Entity Address
ONE BROOKDALE PLAZA
BROOKLYN, NY 11212
Medicare Provider Number
330233
Participating Start Date
10/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
475 NEW LOTS AVENUE PHARMACY INC
Pharmacy Address
475 NEW LOTS AVENUE
ATTN: SUPERVISING PHARMACIST
BROOKLYN, NY 11207
Pharmacy Comments
Contract Details
Approval Date
4/18/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Porter, CFO
(718) 240-5773
Contract Pharmacy Representative
Boca Pharmacy
Jacob Jamron, CEO
(718) 991-6700
Signed By Date
4/18/2018
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