Covered Entity Details

RRC300019-07 CHESHIRE MEDICAL CENTER (Approved) - information as of 6/14/2025 10:04:27 AM

Main Details

Name

CHESHIRE MEDICAL CENTER

Subdivision Name

CHESHIRE MEDICAL CENTER - Maple Ave - Family and Community Care

Type

Rural Referral Center

Rural

Yes

340B ID

RRC300019-07

Medicare Provider Number

300019

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/9/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/15/2025

Last Recertification Date

Contacts

Authorizing Official

Cheshire Medical Center
Kathryn Willbarger, COO
(603) 354-5488

Primary Contact

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

Addresses

Street Address

62 MAPLE AVE
KEENE, NH 03431-1625

Billing Address

Cheshire Medical Center
580 Court Street
Keene, NH 03431

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

Cheshire Medical Center
580 Court Street
Keene, NH 03431

Shipping Address 2

Cheshire Medical Center DBA The Clinic Pharmacy Central Supply
1000 Quality Drive
DBA Dartmouth-Hitchcock Pharmacy
Hooksett, NH 03106

Shipping Address 3

Safecor/Cheshire Medical Center
317 New Boston Street
Woburn, MA 01801

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
RRC300019-01	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Winchester Family Practice	20 WARWICK RD	WINCHESTER	NH	Active
RRC300019-02	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Walpole Family Practice	11 WESTMINSTER ST	WALPOLE	NH	Active
RRC300019-03	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Ophthalmology Vision Care	149 EMERALD ST	KEENE	NH	Active
RRC300019-04	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Dermatology	51 RAILROAD ST	KEENE	NH	Active
RRC300019-05	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Emerald General Surgery	149 EMERALD ST	KEENE	NH	Active
RRC300019-06	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Marlboro Geriatrics	312 MARLBORO ST	KEENE	NH	Active
RRC300019-07	Child	RRC	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Maple Ave - Family and Community Care	62 MAPLE AVE	KEENE	NH	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Willbarger, Kathryn COO Cheshire Medical Center 6033545488	4/15/2025 10:05 AM
Details	340B ID	Update	New Registration		RRC300019-07	4/15/2025 10:05 AM
Details	Entity Subname	Update	New Registration	CHESHIRE MEDICAL CENTER	CHESHIRE MEDICAL CENTER - Maple Ave - Family and Community Care	4/15/2025 10:05 AM
Dates	Participating Approval Date	Update	New Registration		4/15/2025 10:05:05 AM	4/15/2025 10:05 AM
Details	State	Update	New Registration	Pending	Approved	4/15/2025 10:05 AM
Dates	Signed By Date	Update	New Registration		4/9/2025 3:08:16 PM	4/15/2025 10:05 AM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/15/2025 10:05 AM
Addresses	Main Address	Insert	New Registration		62 MAPLE AVE KEENE, NH 03431-1625	4/9/2025 1:29 PM
Addresses	Billing Address	Insert	New Registration		Cheshire Medical Center 580 Court Street Keene, NH 03431	4/9/2025 1:29 PM
Addresses	Shipping Address	Insert	New Registration		Cheshire Medical Center 580 Court Street Keene, NH 03431	4/9/2025 1:29 PM
Addresses	Shipping Address	Insert	New Registration		Cheshire Medical Center DBA The Clinic Pharmacy Central Supply 1000 Quality Drive DBA Dartmouth-Hitchcock Pharmacy Hooksett, NH 03106	4/9/2025 1:29 PM
Addresses	Shipping Address	Insert	New Registration		Safecor/Cheshire Medical Center 317 New Boston Street Woburn, MA 01801	4/9/2025 1:29 PM
Contacts	Primary Contact	Insert	New Registration		Chupka, Kristin A Director - Pharmacy System 340B Program Dartmouth-Hitchcock 6036560945	4/9/2025 1:29 PM
Contacts	Authorizing Official	Insert	New Registration		Willbarger, Kathryn COO Cheshire Medical Center 6033545488	4/9/2025 1:29 PM
Details	Assistance Received From Date	Insert	New Registration			4/9/2025 1:29 PM
Details	Assistance Received To Date	Insert	New Registration			4/9/2025 1:29 PM
Details	Last Recertification Date	Insert	New Registration			4/9/2025 1:29 PM
Details	Grant Number	Insert	New Registration			4/9/2025 1:29 PM
Details	340B ID	Insert	New Registration			4/9/2025 1:29 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2025 1:29 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2025 1:29 PM
Details	Medicare Provider Number	Insert	New Registration		300019	4/9/2025 1:29 PM
Details	Entity Name	Insert	New Registration		CHESHIRE MEDICAL CENTER	4/9/2025 1:29 PM
Details	NOFO Number	Insert	New Registration			4/9/2025 1:29 PM
Details	Program Code	Insert	New Registration		RRC	4/9/2025 1:29 PM
Details	Entity Subname	Insert	New Registration		CHESHIRE MEDICAL CENTER	4/9/2025 1:29 PM
Dates	Participating Approval Date	Insert	New Registration			4/9/2025 1:29 PM
Details	State	Insert	New Registration		Pending	4/9/2025 1:29 PM
Dates	Registration Date	Insert	New Registration		4/9/2025 1:29:25 PM	4/9/2025 1:29 PM
Dates	Signed By Date	Insert	New Registration			4/9/2025 1:29 PM
Dates	Start Date	Insert	New Registration			4/9/2025 1:29 PM
Terminations	Termination Comments	Insert	New Registration			4/9/2025 1:29 PM
Terminations	Termination Date	Insert	New Registration			4/9/2025 1:29 PM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2025 1:29 PM
Terminations	Termination Reason	Insert	New Registration			4/9/2025 1:29 PM