Covered Entity Details

DSH300003CM MARY HITCHCOCK MEMORIAL HOSP (Active) - information as of 6/4/2025 1:21:08 PM

Main Details

Name

MARY HITCHCOCK MEMORIAL HOSP

Subdivision Name

MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua General Internal Medicine (GIM)

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH300003CM

Medicare Provider Number

300003

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/12/2024

Participating Start Date

4/1/2024

Participating Approval Date

2/9/2024

Last Recertification Date

8/29/2024

Contacts

Authorizing Official

Dartmouth Health
Keith B Thomasset, Chief Pharmacy Officer
(603) 656-0966

Primary Contact

Dartmouth-Hitchcock
Kristin A Chupka, Director - Pharmacy System 340B Program
(603) 656-0945

Addresses

Street Address

2300 SOUTHWOOD DR
2nd Floor
NASHUA, NH 03063-1818

Billing Address

Mary Hitchcock Memorial Hospital
One Medical Center Drive
LEBANON, NH 03756-0001

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Mary Hitchcock Memorial Hospital
One Medical Center Drive
LEBANON, NH 03756-0001

Shipping Address 2

Mary Hitchcock Memorial Hospital
50 North Labombard Road
LEBANON, NH 03766

Shipping Address 3

The Clinc Pharmacy Central Supply
1000 Quality Drive
Hooksett, NH 03106

Shipping Address 4

Dartmouth-Hitchcock Pharmacy at Centerra
12 Centerra Parkway
Suite 10
Lebanon, NH 03766-1411

Shipping Address 5

Mary Hitchcock Memorial Hospital
1000 Quality Drive
Hooksett, NH 03106

Shipping Address 6

D-H Pharmacy
1000 Quality Drive
Hooksett, NH 03106

Shipping Address 7

Mary Hitchcock Memorial Hospital
100 Hitchcock Way
Manchester, NH 03104

Shipping Address 8

Mary Hitchcock Memorial Hospital
2300 SOUTHWOOD DR
NASHUA, NH 03063

Shipping Address 9

Mary Hitchcock Memorial Hospital
1080 Hospital Dr
Saint Johnsbury, VT 05819-6001

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH300003A	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater ALS/Neurology Clinic	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003AA	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Podiatry	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AB	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Pulmonology	87 MCGREGOR ST	MANCHESTER	NH	Active
DSH300003AC	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Vascular Services	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AD	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Urology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AE	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Nutrition	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AF	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Urgent Care	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AG	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Complex Primary Care	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AH	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford OB/GYN Specialties	5 WASHINGTON PL	BEDFORD	NH	Active
DSH300003AJ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Nutrition	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AK	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric General Surgery	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AL	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Pediatric Endocrinology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003AM	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Sleep Medicine	87 MCGREGOR ST	MANCHESTER	NH	Active
DSH300003AN	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology:Cat Scan	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AP	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester General Surgery	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AQ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatrics	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AR	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford General Internal Medicine (GIM)	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AS	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology: XRAY Medical Office Building (MOB)	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AT	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Nephrology	87 MCGREGOR ST	MANCHESTER	NH	Active
DSH300003AU	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Hematology Oncology	100 Hitchcock Way	Manchester	NH	Active
DSH300003AV	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Dermatology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AW	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Cardiology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AX	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Neurology	87 McGregor St	MANCHESTER	NH	Active
DSH300003AY	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Cystic Fibrosis	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003AZ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford OB/GYN	5 WASHINGTON PL	BEDFORD	NH	Active
DSH300003B	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	NORRIS COTTON CANCER CENTER NASHUA - Oncology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003BA	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Family Practice	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BB	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Endocrinology	87 MCGREGOR ST	MANCHESTER	NH	Active
DSH300003BC	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester General Internal Medicine (GIM)	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BD	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Nephrology	87 McGregor St	MANCHESTER	NH	Active
DSH300003BE	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Dermatology MOHS	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BF	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Canton Otolaryngology	30 CANTON ST	MANCHESTER	NH	Active
DSH300003BG	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Endocrinology	87 McGregor St	MANCHESTER	NH	Active
DSH300003BH	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Orthopaedics	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BJ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Pediatrics	58 Hawthorne Drive	Bedford	NH	Active
DSH300003BK	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Palliative Care	100 Hitchcock Way	Manchester	NH	Active
DSH300003BL	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pain Management	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BM	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Weight Wellness	5 WASHINGTON PL	BEDFORD	NH	Active
DSH300003BN	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Radiology/Ultrasound	5 WASHINGTON PL	BEDFORD	NH	Active
DSH300003BP	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology: Mammography	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BQ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Cardiology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BR	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology: MRI	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BS	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Med Infusion	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BT	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Genetics	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BU	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Neurology	87 MCGREGOR ST	MANCHESTER	NH	Active
DSH300003BV	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Gastroenterology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003BW	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Radiology: Cat Scan	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003BX	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Radiology: Mammography	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003BY	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Pulmonology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003BZ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Weight Wellness	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003C	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Sleep Medicine	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003CA	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Endocrinology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CB	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Nephrology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CC	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Otolaryngology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CD	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua OB GYN	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CE	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Radiology: Ultrasound	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CF	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Cardiology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CG	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Dermatology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CH	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Hudson Family Practice	208 ROBINSON RD	HUDSON	NH	Active
DSH300003CJ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Urgent Care	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CK	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Rheumatology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CL	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Pediatrics Upper	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CM	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua General Internal Medicine (GIM)	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CN	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Infectious Disease	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CP	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Nurse Clinic	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CQ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Neurology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CR	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Palliative Care	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CS	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Vascular Services	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CT	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Radiology: XRAY	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CU	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Radiology: MRI	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CV	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Med Infusion	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CW	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Orthopaedics	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CX	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Allergy	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003CY	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Merrimack Family Practice	294 DANIEL WEBSTER HWY	MERRIMACK	NH	Active
DSH300003CZ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Milford Family Practice	14 ARMORY RD	MILFORD	NH	Active
DSH300003D	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Orthopaedics/Functional Restoration Program	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003DA	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Gastroenterology	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003DB	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Vascular Services	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DC	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord OB GYN	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DD	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord General Surgery	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DE	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Radiology: XRAY	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DF	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Endocrinology	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DG	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Pillsbury Otolaryngology	2 PILLSBURY ST	CONCORD	NH	Active
DSH300003DH	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Dermatology	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DJ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Urgent Care	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DK	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Pillsbury Neurology	2 PILLSBURY ST	CONCORD	NH	Active
DSH300003DL	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Radiology: Mammography	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DM	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Podiatry	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DN	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Rheumatology	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DP	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Radiology: MRI	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DQ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Allergy	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DR	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Radiology:Cat Scan	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DS	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Primary Care	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DT	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Pediatrics	280 PLEASANT ST	CONCORD	NH	Active
DSH300003DU	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Infectious Disease	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DV	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Cardiology	253 PLEASANT ST	CONCORD	NH	Active
DSH300003DW	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Podiatry	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003DX	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Gastroenterology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003DY	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Infectious Disease	5 Washington Place	Bedford	NH	Active
DSH300003DZ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Allergy	5 WASHINGTON PL	BEDFORD	NH	Active
DSH300003E	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Integrative Medicine	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003EA	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Plastic Surgery	100 Hitchcock Way	MANCHESTER	NH	Active
DSH300003EB	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua General Surgery	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003EC	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Family Practice	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003ED	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Radiology: Ultrasound	253 PLEASANT ST	CONCORD	NH	Active
DSH300003EE	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Orthopaedics	253 PLEASANT ST	CONCORD	NH	Active
DSH300003EF	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Hematology Oncology Infusion	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EG	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Occupational Health	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EH	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Behavioral Health	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EJ	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Child Advocacy	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EK	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Musculoskeletal Health	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EL	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Public Health	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EM	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Concord Gastroenterology	253 PLEASANT ST	CONCORD	NH	Active
DSH300003EN	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Neurosurgery	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003EP	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua Public Health	2300 SOUTHWOOD DR	NASHUA	NH	Active
DSH300003F	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH HITCHCOCK LYME - Lyme GIM - Internal Medicine	204 DARTMOUTH COLLEGE HWY	LYME	NH	Active
DSH300003G	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Internal Medicine (2N)	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003H	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Primary Care Walk in Clinic	18 OLD ETNA RD	LEBANON	NH	Terminated
DSH300003J	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Plastic Surgery	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003K	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	NORRIS COTTON CANCER CENTER NORTH - Oncology	1080 HOSPITAL DR	SAINT JOHNSBURY	VT	Active
DSH300003L	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Dermatology	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003M	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Dermatology MOHS-Skin Cancer Care	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003N	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	OUTPATIENT SURGICAL CENTER AT DHMC - Outpatient Surgery	36 Lahaye Drive	Lebanon	NH	Active
DSH300003P	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	DARTMOUTH-HITCHCOCK HEATER ROAD - Heater Family Practice (2S)	18 OLD ETNA RD	LEBANON	NH	Active
DSH300003Q	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Cystic Fibrosis	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003R	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Neonatology	100 HITCHCOCK WAY	MANCHESTER	NH	Terminated
DSH300003S	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Notre Dame Pavilion Hematology Oncology Office	100 Hitchcock Way	Manchester	NH	Active
DSH300003T	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology: XRAY	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003U	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Rheumatology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003V	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Pulmonology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003W	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Radiology: Ultrasound	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003X	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Pediatric Urology	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003Y	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Manchester Diabetic Education	100 HITCHCOCK WAY	MANCHESTER	NH	Active
DSH300003Z	Child	DSH	MARY HITCHCOCK MEMORIAL HOSP	MARY HITCHCOCK MEMORIAL HOSPITAL - Bedford Family Practice	58 Hawthorne Drive	Bedford	NH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Jordan, Patrick F. Chief Operating Officier Dartmouth-Hitchcock 6036505706	Thomasset, Keith B Chief Pharmacy Officer Dartmouth Health 6036560966	9/25/2024 7:59 AM
Addresses	Main Address	Update	Recertification	2300 SOUTHWOOD DR NASHUA, NH 03063-1818	2300 SOUTHWOOD DR 2nd Floor NASHUA, NH 03063-1818	8/29/2024 7:33 AM
Details	Last Recertification Date	Update	Recertification		8/29/2024 7:33:21 AM	8/29/2024 7:33 AM
Addresses	Billing Address	Update	Group Change Request	Mary Hitchcock Memorial Hospital One Medical Center Drive LEBANON, NH 03756	Mary Hitchcock Memorial Hospital One Medical Center Drive LEBANON, NH 03756-0001	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital One Medical Center Drive LEBANON, NH 03756-0001	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital 50 North Labombard Road LEBANON, NH 03766	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		The Clinc Pharmacy Central Supply 1000 Quality Drive Hooksett, NH 03106	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Dartmouth-Hitchcock Pharmacy at Centerra 12 Centerra Parkway Suite 10 Lebanon, NH 03766-1411	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital 1000 Quality Drive Hooksett, NH 03106	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		D-H Pharmacy 1000 Quality Drive Hooksett, NH 03106	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital 100 Hitchcock Way Manchester, NH 03104	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital 2300 SOUTHWOOD DR NASHUA, NH 03063	7/18/2024 1:10 PM
Addresses	Shipping Address	Insert	Group Change Request		Mary Hitchcock Memorial Hospital 1080 Hospital Dr Saint Johnsbury, VT 05819-6001	7/18/2024 1:10 PM
Details	State	Update		Approved	Active	4/1/2024 12:01 AM
Contacts	Authorizing Official	Update	Change Request	Hermann, Staci A CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036533160	Jordan, Patrick F. Chief Operating Officier Dartmouth-Hitchcock 6036505706	2/12/2024 8:16 AM
Contacts	Signed By	Insert	New Registration		Hermann, Staci A CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036533160	2/9/2024 7:38 AM
Details	340B ID	Update	New Registration		DSH300003CM	2/9/2024 7:38 AM
Details	Entity Subname	Update	New Registration	MARY HITCHCOCK MEMORIAL HOSPITAL	MARY HITCHCOCK MEMORIAL HOSPITAL - Nashua General Internal Medicine (GIM)	2/9/2024 7:38 AM
Dates	Participating Approval Date	Update	New Registration		2/9/2024 7:38:46 AM	2/9/2024 7:38 AM
Details	State	Update	New Registration	Pending	Approved	2/9/2024 7:38 AM
Dates	Signed By Date	Update	New Registration		1/25/2024 12:18:27 PM	2/9/2024 7:38 AM
Dates	Start Date	Update	New Registration		4/1/2024 12:00:00 AM	2/9/2024 7:38 AM
Addresses	Main Address	Insert	New Registration		2300 SOUTHWOOD DR NASHUA, NH 03063-1818	1/12/2024 12:27 PM
Addresses	Billing Address	Insert	New Registration		Mary Hitchcock Memorial Hospital One Medical Center Drive LEBANON, NH 03756	1/12/2024 12:27 PM
Contacts	Authorizing Official	Insert	New Registration		Hermann, Staci A CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036533160	1/12/2024 12:27 PM
Contacts	Primary Contact	Insert	New Registration		Chupka, Kristin A Director - Pharmacy System 340B Program Dartmouth-Hitchcock 6036560945	1/12/2024 12:27 PM
Details	Assistance Received From Date	Insert	New Registration			1/12/2024 12:27 PM
Details	Assistance Received To Date	Insert	New Registration			1/12/2024 12:27 PM
Details	Last Recertification Date	Insert	New Registration			1/12/2024 12:27 PM
Details	Grant Number	Insert	New Registration			1/12/2024 12:27 PM
Details	340B ID	Insert	New Registration			1/12/2024 12:27 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/12/2024 12:27 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/12/2024 12:27 PM
Details	Medicare Provider Number	Insert	New Registration		300003	1/12/2024 12:27 PM
Details	Entity Name	Insert	New Registration		MARY HITCHCOCK MEMORIAL HOSP	1/12/2024 12:27 PM
Details	NOFO Number	Insert	New Registration			1/12/2024 12:27 PM
Details	Program Code	Insert	New Registration		DSH	1/12/2024 12:27 PM
Details	Entity Subname	Insert	New Registration		MARY HITCHCOCK MEMORIAL HOSPITAL	1/12/2024 12:27 PM
Dates	Participating Approval Date	Insert	New Registration			1/12/2024 12:27 PM
Details	State	Insert	New Registration		Pending	1/12/2024 12:27 PM
Dates	Registration Date	Insert	New Registration		1/12/2024 12:27:47 PM	1/12/2024 12:27 PM
Dates	Signed By Date	Insert	New Registration			1/12/2024 12:27 PM
Dates	Start Date	Insert	New Registration			1/12/2024 12:27 PM
Terminations	Termination Comments	Insert	New Registration			1/12/2024 12:27 PM
Terminations	Termination Date	Insert	New Registration			1/12/2024 12:27 PM
Terminations	Termination Effective Date	Insert	New Registration			1/12/2024 12:27 PM
Terminations	Termination Reason	Insert	New Registration			1/12/2024 12:27 PM