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RITE AIDE OF NEW YORK
DSH330127 JACOBI MEDICAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
JACOBI MEDICAL CENTER (NYCHHC)
Subdivision Name
FORMERLY BRONX MUNICIPAL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH330127
Entity Address
1400 PELHAM PKWY SOUTH
BRONX, NY 10461
Medicare Provider Number
330127
Participating Start Date
12/1/1992
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
RITE AIDE OF NEW YORK
Pharmacy Address
RITE AID #2703
546-558 WEST 207TH STREET
NEW YORK, NY 10034-2611
Pharmacy Comments
Contract Details
Approval Date
11/8/2012
Contract Begin Date
10/27/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/16/2015
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
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