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PROACT PHARMACY SERVICES, INC.
SCH330223-05 MASSENA HOSPITAL, INC.
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Covered Entity Details
Entity Name
MASSENA HOSPITAL, INC.
Subdivision Name
MMH OB/GYN
Type
Sole Community Hospital
340B ID
SCH330223-05
Entity Address
15 HOSPITAL DR
MASSENA, NY 13662
Medicare Provider Number
330223
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PROACT PHARMACY SERVICES, INC.
Pharmacy Address
1226 US HIGHWAY 11
GOUVERNEUR, NY 13642
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
4/1/2017
Agreement registered in error
Contacts
Covered Entity Signing Official
Patrick Facteau, CFO
(315) 769-4207
Contract Pharmacy Representative
KPH Health
ETHAN THOMAS, 340B COORDINATOR
(315) 287-3600
Signed By Date
3/24/2017
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