Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
DSH330229 Brooks-TLC Hospital System Inc.

Covered Entity Details

Entity Name

Brooks-TLC Hospital System Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330229

Entity Address

529 CENTRAL AVE.
DUNKIRK, NY 14048

Medicare Provider Number

330229

Participating Start Date

2/27/2018

Last Recertification Date

8/29/2023

Entity Termination Date

4/1/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #1649
81 WEST MAIN STREET
GOWANDA, NY 14070

Pharmacy Comments

Contract Details

Approval Date

10/6/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/29/2021
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Kenneth Morris, Chief Operating Officer
(716) 363-7260

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

10/6/2020

340B Drug Pricing Program Database