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KPH HEALTHCARE SERVICES, INC.
DSH330084 ALICE HYDE MEDICAL CENTER
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Covered Entity Details
Entity Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330084
Entity Address
133 PARK STREET
MALONE, NY 12953-0729
Medicare Provider Number
330084
Participating Start Date
10/1/2011
Last Recertification Date
8/29/2023
Entity Termination Date
11/27/2023
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #14
485 EAST MAIN STREET
MALONE, NY 12953
Pharmacy Comments
Contract Details
Approval Date
10/28/2011
Contract Begin Date
10/28/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Chris Frauenhofer, V.P. of Finance
(518) 481-2204
Contract Pharmacy Representative
Owen Halloran, Senior Vice President, Pharmacy Procurement
(315) 287-3600 Ext: 263
Signed By Date
10/26/2011
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