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RITE AID OF PENNSYLVANIA, LLC
DSH390156 MERCY CATHOLIC MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY CATHOLIC MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390156
Entity Address
1500 LANSDOWNE AVE
ATTN: Pharmacy Director
DARBY, PA 19023
Medicare Provider Number
390156
Participating Start Date
7/1/2003
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #4554
6731 WOODLAND AVENUE
PHILADELPHIA, PA 19142
Pharmacy Comments
Contract Details
Approval Date
4/10/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/12/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Wajda, CFO
(215) 335-6281
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
4/10/2017
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