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RITE AID OF NEW YORK, INC.
DSH330396 WOODHULL HOSPITAL CENTER
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Covered Entity Details
Entity Name
WOODHULL HOSPITAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330396
Entity Address
760 BROADWAY
MAIN ENTRANCE: 720 FLUSHING AV
BROOKLYN, NY 11206
Medicare Provider Number
330396
Participating Start Date
12/1/1992
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4991
109-07 101ST AVENUE
JAMAICA, NY 11419
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
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