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RITE AID OF KENTUCKY, INC.
SCH180043-00 Memorial Hospital d/b/a Manchester Memorial Hospital
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Covered Entity Details
Entity Name
Memorial Hospital d/b/a Manchester Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH180043-00
Entity Address
210 Marie Langdon Drive
Manchester, KY 40962
Medicare Provider Number
180043
Participating Start Date
7/1/2014
Last Recertification Date
8/22/2016
Entity Termination Date
10/1/2017
Pharmacy Details
Pharmacy Name
RITE AID OF KENTUCKY, INC.
Pharmacy Address
RITE AID #3916
560 MANCHESTER SQUARE
MANCHESTER, KY 40962
Pharmacy Comments
Contract Details
Approval Date
6/17/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DANIEL WALKER, CFO
(606) 598-1035
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
6/17/2014
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