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RITE AID OF PENNSYLVANIA, LLC
DSH390174 THOMAS JEFFERSON UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390174
Entity Address
111 South 11th Street
Philadelphia, PA 19107
Medicare Provider Number
390174
Participating Start Date
4/1/2006
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #857
169 WEST LANCASTER AVENUE
ARDMORE, PA 19003
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
NEIL G. LUBARSKY, SR VP FOR FINANCE
(215) 955-9993
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
1/15/2020
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