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RITE AID OF PENNSYLVANIA, LLC
DSH390063 UPMC HAMOT
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Covered Entity Details
Entity Name
UPMC HAMOT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390063
Entity Address
201 STATE STREET
ERIE, PA 16550
Medicare Provider Number
390063
Participating Start Date
4/1/2015
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #1376
916 STATE STREET
ERIE, PA 16501
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad N Dinger, CFO
(814) 877-3739
Contract Pharmacy Representative
RiteAid
Mark Thorn, Manager, Pharmacy Replenishment Program
(734) 347-1086
Signed By Date
10/16/2023
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