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RITE AID DRUG PALACE, INC.
DSH390204 NAZARETH HOSPITAL
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Covered Entity Details
Entity Name
NAZARETH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390204
Entity Address
2601 HOLME AVENUE
PHILADELPHIA, PA 19152
Medicare Provider Number
390204
Participating Start Date
10/1/2016
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
RITE AID DRUG PALACE, INC.
Pharmacy Address
RITE AID #553
4011 COTTMAN AVENUE
PHILADELPHIA, PA 19135
Pharmacy Comments
Contract Details
Approval Date
4/4/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/12/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Wajda, CFO
(215) 335-6281
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
4/4/2017
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