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RITE AID OF PENNSYLVANIA, LLC
DSH390027 TEMPLE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
TEMPLE UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390027
Entity Address
3401 North Broad Street
PHILADELPHIA, PA 19140
Medicare Provider Number
390027
Participating Start Date
1/1/2004
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #895
3900 CASTOR AVENUE
PHILADELPHIA, PA 19124
Pharmacy Comments
Contract Details
Approval Date
10/11/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Abhinav Rastogi, President & C.E.O
(215) 707-4299
Contract Pharmacy Representative
RiteAid
Mark Thorn, Manager, Pharmacy Replenishment Program
(734) 347-1086
Signed By Date
10/11/2024
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