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RITE AID OF PENNSYLVANIA, LLC
DSH390194 Blue Mountain Hospital
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Covered Entity Details
Entity Name
Blue Mountain Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390194
Entity Address
211 North 12th Street
Lehighton, PA 18235
Medicare Provider Number
390194
Participating Start Date
7/1/2013
Last Recertification Date
8/18/2020
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #1450
601 DELAWARE AVENUE
PALMERTON, PA 18071
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Andrea Andrae, Director of Finance
(610) 377-7003
Contract Pharmacy Representative
Rite Aid
David Bell, Rep
(717) 761-2633 Ext: 5311
Signed By Date
7/15/2020
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