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RITE AID PHARMACY #10597
DSH330128 ELMHURST HOSPITAL CENTER (NYCHHC)
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Covered Entity Details
Entity Name
ELMHURST HOSPITAL CENTER (NYCHHC)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330128
Entity Address
79-01 BROADWAY
ELMHURST, NY 11373
Medicare Provider Number
330128
Participating Start Date
12/1/1992
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
RITE AID PHARMACY #10597
Pharmacy Address
37-32 82ND STREET
JACKSON HEIGHTS, NY 11372
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
10/21/2015
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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