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WALGREEN EASTERN CO., INC.
SCH330223-01 MASSENA HOSPITAL, INC.
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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
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS # 10293
173 MARKET ST
POTSDAM, NY 13676-1221
Pharmacy Comments
Contract Details
Approval Date
7/13/2017
Contract Begin Date
10/1/2017
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
CHARLES DAVIS, 340 B, PHARMACIST
(315) 265-6291
Signed By Date
7/13/2017
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