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RITE AID OF NEW YORK, INC.
SCH330079-00 Adirondack Medical Center
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Covered Entity Details
Entity Name
Adirondack Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330079-00
Entity Address
2233 State Route 86
Saranac Lake, NY 12983
Medicare Provider Number
330079
Participating Start Date
10/1/2015
Last Recertification Date
8/30/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #3594
173 CHURCH STREET
SARANAC LAKE, NY 12983
Pharmacy Comments
Contract Details
Approval Date
8/27/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/23/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charles Glanville, Chief Financial Officer
(518) 897-2301
Contract Pharmacy Representative
Rite Aid
Chris Hall, Senior Vice President
(717) 214-8834
Signed By Date
8/27/2015
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