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RITE AID OF NEW YORK, INC.
DSH330194 MAIMONIDES MEDICAL CENTER
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Covered Entity Details
Entity Name
MAIMONIDES MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330194
Entity Address
4802 TENTH AVE.
BROOKLYN, NY 11219
Medicare Provider Number
330194
Participating Start Date
10/1/2004
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4259
6101 18TH AVENUE
BROOKLYN, NY 11204
Pharmacy Comments
Contract Details
Approval Date
4/12/2013
Contract Begin Date
4/12/2013
Carve-In Effective Date
Contract Comments
04/12/2013 - public health emergency declared in the state of NY effective 10/27/2012
Contract Termination Date
Termination Reason
3/13/2018
Ownership change
Contacts
Covered Entity Signing Official
PAMELA BRIER, CEO
(718) 283-6009
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/12/2013
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