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MARTIN'S FOODS OF SOUTH BURLINGTON, LLC
DSH330047 ST. MARYS HEALTHCARE
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Covered Entity Details
Entity Name
ST. MARYS HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330047
Entity Address
427 GUY PARK AVENUE
AMSTERDAM, NY 12010
Medicare Provider Number
330047
Participating Start Date
10/1/2009
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
MARTIN'S FOODS OF SOUTH BURLINGTON, LLC
Pharmacy Address
DBA HANNAFORD FOOD & DRUG #8363
115 HANNAFORD PLAZA
AMSTERDAM, NY 12010
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/23/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rick Henze, Vice President of Finance/CFO
(518) 841-7435
Contract Pharmacy Representative
Hannaford
Mike Fish, Pharmacy District Manager
(518) 428-2712
Signed By Date
4/15/2021
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