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RITE AID OF PENNSYLVANIA, LLC
DSH390118 BRADFORD REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BRADFORD REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390118
Entity Address
116-56 INTERSTATE PARKWAY
BRADFORD, PA 16701
Medicare Provider Number
390118
Participating Start Date
7/1/2005
Last Recertification Date
11/6/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #1406
521 NORTH FRALEY STREET
KANE, PA 16735
Pharmacy Comments
Contract Details
Approval Date
1/8/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Richard G. Braun Jr., SVP Finance and CFO
(716) 375-6190
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
1/8/2016
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