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RITE AID OF NEW YORK, INC.
DSH330028 RICHMOND UNIVERSITY MEDICAL CENTER
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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 #4712
9302 3RD AVENUE
BROOKLYN, NY 11209
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
7/13/2023
Business decision by covered entity and/or pharmacy
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
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