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RITE AID OF NEW YORK, INC.
DSH330197 CANTON-POTSDAM HOSPITAL
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Covered Entity Details
Entity Name
CANTON-POTSDAM HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330197
Entity Address
50 LEROY STREET
POTSDAM, NY 13676
Medicare Provider Number
330197
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4998
87 MAIN STREET
MASSENA, NY 13662
Pharmacy Comments
Contract Details
Approval Date
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
RICHARD D. JACOBS, VP FOR FINANCE AND CFO
(315) 261-5100
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
7/16/2018
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