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RITE AID OF NEW YORK, 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
RITE AID OF NEW YORK, INC.
Pharmacy Address
RITE AID #4998
87 MAIN STREET
MASSENA, NY 13662
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
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Patrick Facteau, CFO
(315) 769-4207
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/4/2017
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