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PROACT PHARMACY SERVICES, INC.
DSH330084 ALICE HYDE MEDICAL CENTER
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Covered Entity Details
Entity Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330084
Entity Address
133 PARK STREET
MALONE, NY 12953-0729
Medicare Provider Number
330084
Participating Start Date
10/1/2011
Last Recertification Date
8/29/2023
Entity Termination Date
11/27/2023
Pharmacy Details
Pharmacy Name
PROACT PHARMACY SERVICES, INC.
Pharmacy Address
1226 US HIGHWAY 11
GOUVERNEUR, NY 13642
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
SCOTT ST. GEORGE, SENIOR VICE PRESIDENT/CHIEF FINANCIAL OFFICER
(518) 562-7047
Contract Pharmacy Representative
KPH Healthcare Services, Inc.
Debbi Barber, 340B Program Director
(315) 287-3600 Ext: 2423
Signed By Date
4/16/2018
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