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THE GOLUB CORPORATION
SCH330136-00 MARY IMOGENE BASSETT HOSPITAL
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Covered Entity Details
Entity Name
MARY IMOGENE BASSETT HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330136-00
Entity Address
1 ATWELL ROAD
COOPERSTOWN, NY 13326
Medicare Provider Number
330136
Participating Start Date
7/1/2024
Last Recertification Date
8/29/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
THE GOLUB CORPORATION
Pharmacy Address
PRICE CHOPPER PHARMACY 161
5631 STATE HIGHWAY 12
NORWICH, NY 13815
Pharmacy Comments
Contract Details
Approval Date
4/30/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Vielkind, Vice President Finance
(315) 823-5281
Contract Pharmacy Representative
Price Chopper
Angel Adams, Pharmacy Manager
(607) 336-2588
Signed By Date
4/12/2024
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