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KPH HEALTHCARE SERVICES, INC.
DSH330197 CANTON-POTSDAM HOSPITAL
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Covered Entity Details
Entity Name
CANTON-POTSDAM HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330197
Entity Address
50 LEROY STREET
POTSDAM, NY 13676
Medicare Provider Number
330197
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #01
17 CLINTON STREET
GOUVERNEUR, NY 13642
Pharmacy Comments
Contract Details
Approval Date
1/13/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RICHARD D. JACOBS, VP FOR FINANCE AND CFO
(315) 261-5100
Contract Pharmacy Representative
Debbi Barber, Director of PBM Relations
(315) 287-3600 Ext: 2423
Signed By Date
1/13/2017
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