Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
DSH330127 JACOBI MEDICAL CENTER (NYCHHC)

Covered Entity Details

Entity Name

JACOBI MEDICAL CENTER (NYCHHC)

Subdivision Name

FORMERLY BRONX MUNICIPAL HOSPITAL

Type

Disproportionate Share Hospital

340B ID

DSH330127

Entity Address

1400 PELHAM PKWY SOUTH
BRONX, NY 10461

Medicare Provider Number

330127

Participating Start Date

12/1/1992

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #3817
57 EAST BURNSIDE AVENUE
BRONX, NY 10453

Pharmacy Comments

Contract Details

Approval Date

1/11/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/5/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Paul Albertson, Vice President
(212) 748-2256

Contract Pharmacy Representative

Rite Aid
David Bell, Rep
(717) 761-2633 Ext: 5311

Signed By Date

1/11/2022

340B Drug Pricing Program Database