Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
DSH330047 ST. MARYS HEALTHCARE

Covered Entity Details

Entity Name

ST. MARYS HEALTHCARE

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330047

Entity Address

427 GUY PARK AVENUE
AMSTERDAM, NY 12010

Medicare Provider Number

330047

Participating Start Date

10/1/2009

Last Recertification Date

8/14/2024

Pharmacy Details

Pharmacy Name

RITE AID OF NEW YORK, INC.

Pharmacy Address

RITE AID #884
9 EAST GRAND STREET
PALATINE BRIDGE, NY 13428

Pharmacy Comments

Contract Details

Approval Date

10/18/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/26/2018
Ownership change

Contacts

Covered Entity Signing Official

Keith Waters, Sr. Director Of Finance
(518) 770-7583

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

10/18/2016

340B Drug Pricing Program Database