Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
DSH330221 WYCKOFF HEIGHTS MEDICAL CENTER

Covered Entity Details

Entity Name

WYCKOFF HEIGHTS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330221

Entity Address

374 STOCKHOLM STREET
BROOKLYN, NY 11237

Medicare Provider Number

330221

Participating Start Date

10/4/2019

Last Recertification Date

8/18/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #4991
109-07 101ST AVENUE
JAMAICA, NY 11419

Pharmacy Comments

Contract Details

Approval Date

10/7/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/30/2018
Ownership change

Contacts

Covered Entity Signing Official

Ramon Rodriguez, President and CEO
(718) 963-7101

Contract Pharmacy Representative

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

Signed By Date

10/7/2013

340B Drug Pricing Program Database