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RITE AID OF PENNSYLVANIA, LLC
DSH390080 JEANES HOSPITAL
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Covered Entity Details
Entity Name
JEANES HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390080
Entity Address
7600 CENTRAL AVENUE
PHILADELPHIA, PA 19111
Medicare Provider Number
390080
Participating Start Date
10/1/2017
Last Recertification Date
8/19/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
RITE AID OF PENNSYLVANIA, LLC
Pharmacy Address
RITE AID #552
6401 OXFORD AVENUE
PHILADELPHIA, PA 19111
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Ownership change
Contacts
Covered Entity Signing Official
Ray Lefton, Chief Financial Officer, Treasurer
(215) 728-3306
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/16/2017
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