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RITE AID OF NEW YORK, INC.
CH02179Q HUDSON HEADWATERS HEALTH NETWORK
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Covered Entity Details
Entity Name
HUDSON HEADWATERS HEALTH NETWORK
Subdivision Name
West Mountain Family Health and West Mountain Specialty Care
Type
HRSA-Funded Health Center
340B ID
CH02179Q
Entity Address
161 CAREY ROAD
QUEENSBURY, NY 12804-7880
Grant Number
H80CS00159
Participating Start Date
7/1/2012
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4722
887 STATE ROUTE 11
PO BOX 576
CHAMPLAIN, NY 12919
Pharmacy Comments
Contract Details
Approval Date
11/9/2012
Contract Begin Date
10/27/2012
Carve-In Effective Date
Contract Comments
11/05/2012 - public health emergency declared in the state of NY effective 10/27/2012
Contract Termination Date
Termination Reason
2/8/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
George Purdue, Chief Administrative Officer
(518) 761-0300 Ext: 31114
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/1/2012
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