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RITE AID OF NEW YORK, INC.
DSH330241 UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330241
Entity Address
750 East Adams Street
Syracuse, NY 13210
Medicare Provider Number
330241
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #633
1819 WEST GENESEE ST., STE 3
SYRACUSE, NY 13204
Pharmacy Comments
Contract Details
Approval Date
10/15/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/20/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul Seale, Chief Operating Officer
(315) 464-6530
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/15/2013
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