Contract Pharmacy Details

GENOVESE DRUG STORES, INC.
DSH330127 JACOBI MEDICAL CENTER (NYCHHC)

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

GENOVESE DRUG STORES, INC.

Pharmacy Address

RITE AID #10577
8222 18TH AVENUE
BROOKLYN, NY 11214

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

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
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217

Signed By Date

10/27/2012

340B Drug Pricing Program Database