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WALGREEN EASTERN CO., INC.
SCH330223-06 MASSENA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MASSENA MEMORIAL HOSPITAL
Subdivision Name
MMH NORFOLK CLINIC
Type
Sole Community Hospital
340B ID
SCH330223-06
Entity Address
42 WEST MAIN ST
NORFOLK, NY 13667
Medicare Provider Number
330223
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
8/19/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS #10591
305 W. MAIN ST.
MALONE, NY 12953-1751
Pharmacy Comments
Contract Details
Approval Date
3/24/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Patrick Facteau, CFO
(315) 769-4207
Contract Pharmacy Representative
BRYAN TROMBLEY, 340 B, PHARMACIST
(518) 483-9090
Signed By Date
3/24/2017
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