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RITE AID DRUG PALACE, INC.
DSH330014 JAMAICA HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
JAMAICA HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330014
Entity Address
8900 VAN WYCK EXPRESSWAY
JAMAICA, NY 11418
Medicare Provider Number
330014
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
RITE AID DRUG PALACE, INC.
Pharmacy Address
RITE AID #1809
222-14 LINDEN BOULEVARD
CAMBRIA HEIGHTS, NY 11411
Pharmacy Comments
Contract Details
Approval Date
7/13/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/21/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
MOUNIR F. DOSS, EXECUTIVE VP & CFO
(718) 206-6291
Contract Pharmacy Representative
Rite Aid Pharmacy
Christopher Moen, VP, Strategic Pharmacy Relations
(717) 791-3129
Signed By Date
7/13/2022
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