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WALGREEN EASTERN CO., INC.
CAH331321-00 ALICE HYDE MEDICAL CENTER
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Covered Entity Details
Entity Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH331321-00
Entity Address
133 PARK STREET
MALONE, NY 12953
Medicare Provider Number
331321
Participating Start Date
11/27/2023
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS #10591
305 W. MAIN ST.
MALONE, NY 12953-1751
Pharmacy Comments
Contract Details
Approval Date
11/27/2023
Contract Begin Date
11/27/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/21/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065
Contract Pharmacy Representative
Walgreen Co.
Nicholas Covarrubias, Analyst
(847) 527-3072
Signed By Date
11/21/2023
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