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RITE AID OF PENNSYLVANIA, LLC
CAH391307-00 TYRONE HOSPITAL
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Covered Entity Details
Entity Name
TYRONE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH391307-00
Entity Address
187 HOSPITAL DRIVE
TYRONE, PA 16686
Medicare Provider Number
391307
Participating Start Date
9/23/2010
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #6740
3106 E PLEASANT VALLEY
ALTOONA, PA 16601
Pharmacy Comments
Contract Details
Approval Date
10/21/2014
Contract Begin Date
10/22/2014
Carve-In Effective Date
Contract Comments
10/22/2014 Immediate Contract begin date authorized
Contacts
Covered Entity Signing Official
STEPHEN C. GILDEA, CEO
(814) 684-6378
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/21/2014
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