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RITE AID OF NEW YORK, INC.
DSH330221 WYCKOFF HEIGHTS MEDICAL CENTER
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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 #4856
122-02 LIBERTY AVENUE
SOUTH RICHMOND HILL, 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
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