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RITE AID OF NEW YORK, INC.
DSH330188 Mount St. Mary's Hospital and Health Center
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Covered Entity Details
Entity Name
Mount St. Mary's Hospital and Health Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330188
Entity Address
5300 MILITARY ROAD
LEWISTON, NY 14092
Medicare Provider Number
330188
Participating Start Date
1/1/2014
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #1148
1717 PINE AVENUE
NIAGARA FALLS, NY 14301
Pharmacy Comments
Contract Details
Approval Date
10/13/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Judith A. Maness, President/CEO
(716) 298-2004
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/13/2014
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