Contract Pharmacy Details

RITE AID OF NEW YORK, INC.
SCH330223-01 MASSENA HOSPITAL, INC.

Covered Entity Details

Entity Name

MASSENA HOSPITAL, INC.

Subdivision Name

MMH KIDS

Type

Sole Community Hospital

340B ID

SCH330223-01

Entity Address

17 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

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

10/1/2017
Agreement registered in error

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

340B Drug Pricing Program Database