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RITE AID OF NEW YORK, INC.
SCH330211-00 Claxton Hepburn Medical Center
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Covered Entity Details
Entity Name
Claxton Hepburn Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330211-00
Entity Address
214 King Street
Ogdensburg, NY 13669
Medicare Provider Number
330211
Participating Start Date
1/1/2014
Last Recertification Date
8/17/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4998
87 MAIN STREET
MASSENA, NY 13662
Pharmacy Comments
Contract Details
Approval Date
7/1/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kelley M. Tiernan, CFO
(315) 713-5350
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
7/1/2014
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