Contract Pharmacy Details

RITE AID OF NEW YORK, 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

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #2669
2063 BARTOW AVENUE
BRONX, NY 10475-4613

Pharmacy Comments

Contract Details

Approval Date

10/13/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

10/13/2016

340B Drug Pricing Program Database