Contract Pharmacy Details

PROACT PHARMACY SERVICES, INC.
SCH330223-02 MASSENA HOSPITAL, INC.

Covered Entity Details

Entity Name

MASSENA HOSPITAL, INC.

Subdivision Name

MMH WALKIN CLINIC

Type

Sole Community Hospital

340B ID

SCH330223-02

Entity Address

one hospital drive
MASSENA, NY 13662

Medicare Provider Number

330223

Outpatient Facility Provider Number

Participating Start Date

4/1/2017

Last Recertification Date

8/17/2020

Entity Termination Date

10/1/2022

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

340B Drug Pricing Program Database