Contract Pharmacy Details

RITE AID OF NEW YORK
DSH330231 QUEENS HOSPITAL CENTER (NYCHHC)

Covered Entity Details

Entity Name

QUEENS HOSPITAL CENTER (NYCHHC)

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330231

Entity Address

82-68 164TH ST.
JAMAICA, NY 11432

Medicare Provider Number

330231

Participating Start Date

12/1/1992

Last Recertification Date

9/4/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK

Pharmacy Address

RITE AID # 4187
2712 BROADWAY
NEW YORK, NY 10025-8701

Pharmacy Comments

Contract Details

Approval Date

11/9/2012

Contract Begin Date

10/27/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/23/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Antonio Martin, Ececutive Vice President & Chief Operating Officier
(212) 788-3479

Contract Pharmacy Representative

Rite Aid
Ruth Lightner, Director
(717) 731-6524

Signed By Date

10/27/2012

340B Drug Pricing Program Database