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RITE AID OF NEW YORK, INC.
DSH330163 EASTERN NIAGARA HOSPITAL
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Covered Entity Details
Entity Name
EASTERN NIAGARA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330163
Entity Address
521 EAST AVENUE
LOCKPORT, NY 14094
Medicare Provider Number
330163
Participating Start Date
4/16/2021
Last Recertification Date
8/16/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #3500
3636 RANSOMVILLE ROAD
RANSOMVILLE, NY 14131
Pharmacy Comments
Contract Details
Approval Date
4/16/2021
Contract Begin Date
6/3/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Osborne, Vice President, Finance
(716) 828-2011
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President Managed Care
(717) 975-5978
Signed By Date
4/12/2021
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