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MARTIN'S FOODS OF SOUTH BURLINGTON, LLC
RRC330191-00 GLENS FALLS HOSPITAL
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Covered Entity Details
Entity Name
GLENS FALLS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330191-00
Entity Address
100 PARK ST
GLENS FALLS, NY 12801
Medicare Provider Number
330191
Participating Start Date
8/18/2020
Last Recertification Date
9/15/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
MARTIN'S FOODS OF SOUTH BURLINGTON, LLC
Pharmacy Address
DBA HANNAFORD SUPERMARKET & PHARMACY #83
3758 BURGOYNE AVENUE
HUDSON FALLS, NY 12839
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul J Scimeca, Senior Vice President/Chief Operating Officer
(518) 926-5902
Contract Pharmacy Representative
Hannaford
Mike Fish, Pharmacy District Manager
(518) 428-2712
Signed By Date
10/14/2020
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