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RITE AID OF PENNSYLVANIA, LLC
DSH390185 LEHIGH VALLEY HOSPITAL-HAZLETON
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Covered Entity Details
Entity Name
LEHIGH VALLEY HOSPITAL-HAZLETON
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390185
Entity Address
700 EAST BROAD STREET
HAZLETON, PA 18201
Medicare Provider Number
390185
Participating Start Date
4/1/2019
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #4840
1000 NORTH CHURCH STREET
HAZELTON, PA 18201
Pharmacy Comments
Contract Details
Approval Date
10/8/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/26/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thomas Marchozzi, Executive Vice President & Chief Financial Officer
(484) 862-3943
Contract Pharmacy Representative
Rite Aid Pharmacy
Christopher Moen, VP, Strategic Pharmacy Relations
(717) 791-3129
Signed By Date
10/8/2021
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