Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
DSH330028 RICHMOND UNIVERSITY MEDICAL CENTER

Covered Entity Details

Entity Name

RICHMOND UNIVERSITY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330028

Entity Address

355 BARD AVENUE
STATEN ISLAND, NY 10310

Medicare Provider Number

330028

Participating Start Date

11/17/2005

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #4565
2532-54 86TH STREET
BROOKLYN, NY 11214

Pharmacy Comments

Contract Details

Approval Date

7/12/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/13/2018
Pharmacy closed

Contacts

Covered Entity Signing Official

MICHAEL BRESLIN, EVP Administration & Finance/CFO
(718) 818-3295

Contract Pharmacy Representative

Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217

Signed By Date

7/12/2013

340B Drug Pricing Program Database