Covered Entity Details

RW424881A Mary Hitchcock Memorial Hospital dba Ryan White Program (Terminated) - information as of 4/29/2025 1:43:14 AM

Main Details

Name

Mary Hitchcock Memorial Hospital dba Ryan White Program

Subdivision Name

Dartmouth-Hitchcock Manchester, Ryan White Part D

Type

Ryan White Part D

340B ID

RW424881A

Grant Number

H12HA31112

Additional Details

Current Program Status

Terminated

Registration Date

4/13/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/21/2016

Last Recertification Date

2/9/2018

Time Period the Assistance was Received

Termination Date
Termination Reason

1/1/2019
Other

Contacts

Authorizing Official

Dartmouth-Hitchcock
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160

Primary Contact

Dartmouth Hitchcock
Michael Lessard, Director of System Pharmacy Operations
(603) 653-2387

Addresses

Street Address

100 Hitchcock Way
Manchester, NH 03104

Billing Address

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

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
Based on documentation provided by the entity, OPA determined that the contract pharmacies were eligible back to January 1, 2018.	12/13/2018

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

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10278	270 MAMMOTH ROAD	MANCHESTER	NH	03109	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10274	122 MCGREGOR STREET STE 4	MANCHESTER	NH	03102	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10276	53 HOOKSETT ROAD	MANCHESTER	NH	03104	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10287	200 PLEASANT STREET	BERLIN	NH	03570	04/21/2016	07/01/2016	01/25/2018	02/02/2018
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10270	331 MAIN STREET	NASHUA	NH	03060	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	MAXI DRUG NORTH, INC.	RITE AID #10283	24 FORT EDDY PLAZA	CONCORD	NH	03301	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	MAXI GREEN, INC.	RITE AID #10317	158 CHERRY STREET	BURLINGTON	VT	05401	04/21/2016	07/01/2016	01/31/2018	02/02/2018
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #1327	910 ROUTE 16	OSSIPEE	NH	03864	04/21/2016	07/01/2016	01/25/2018	02/02/2018
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4993	46 ALLENSTOWN ROAD	ALLENSTOWN	NH	03275	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4741	1631 ELM STREET	MANCHESTER	NH	03101	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4139	1623 WHITE MOUNTAIN HIGHWAY	NORTH CONWAY	NH	03860	04/21/2016	07/01/2016	01/25/2018	02/02/2018
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4282	92 SOUTH STREET	CONCORD	NH	03301	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	RITE AID OF NEW HAMPSHIRE, INC.	RITE AID #4156	50 MAIN STREET PO BOX 538	LINCOLN	NH	03251	04/21/2016	07/01/2016	01/01/2019	01/01/2019
Contract Detail	RITE AID OF VERMONT, INC.	RITE AID #3201	621 ROUTE 22A N	FAIR HAVEN	VT	05743-9239	04/21/2016	07/01/2016	01/31/2018	02/02/2018
Contract Detail	RITE AID OF VERMONT, INC.	RITE AID #1174	P.O. BOX 90 294 MAIN STREET	WEST RUTLAND	VT	05777	04/21/2016	07/01/2016	01/31/2018	02/02/2018
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 04689	606 VALLEY STREET	MANCHESTER	NH	03103	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09613	283 MAIN ST	NASHUA	NH	03060-2937	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11376	142 LOUDON RD.	CONCORD	NH	03301-5637	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09320	258 WALLACE RD	BEDFORD	NH	03110	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 03900	227 S MAIN ST	MANCHESTER	NH	03102	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11505	217 DANIEL WEBSTER	NASHUA	NH	03060-5503	01/16/2018	04/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: RITE AID #04139	1623 WHITE MOUNTAIN HIGHWAY	NORTH CONWAY	NH	03860	05/16/2018	07/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18354	621 ROUTE 22A N	FAIR HAVEN	VT	05743	05/16/2018	07/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17583	173 PLEASANT ST	BERLIN	NH	03570	05/16/2018	07/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18278	294 MAIN ST	WEST RUTLAND	VT	05777	05/16/2018	07/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #19449	158 CHERRY ST	BURLINGTON	VT	05401	05/16/2018	07/01/2018	01/01/2019	01/01/2019
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #19912	910 ROUTE 16	OSSIPEE	NH	03864-7171	05/16/2018	07/01/2018	01/01/2019	01/01/2019

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	1/1/2019 12:05 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		12/31/2018 12:00:00 AM	12/13/2018 2:08 PM
Details	State	Update	Termination Request	Active	To Be Terminated	12/13/2018 2:08 PM
Terminations	Termination Comments	Update	Termination Request		Grant change	12/13/2018 2:08 PM
Terminations	Termination Date	Update	Termination Request		1/1/2019 12:00:00 AM	12/13/2018 2:08 PM
Terminations	Termination Effective Date	Update	Termination Request		1/1/2019 12:00:00 AM	12/13/2018 2:08 PM
Terminations	Termination Reason	Update	Termination Request		Other	12/13/2018 2:08 PM
Details	Comments Public	Insert	OPA Edit		Based on documentation provided by the entity, OPA determined that the contract pharmacies were eligible back to January 1, 2018.	12/13/2018 1:25 PM
Contacts	Authorizing Official	Update	Change Request	Jantzen, Daniel P. Chief Financial Officer Dartmouth Hitchcock 6036508136	Hermann, Staci A CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036533160	12/6/2018 12:42 PM
Contacts	Authorizing Official	Update	Change Request	Siepka, Thomas J. CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036505738	Jantzen, Daniel P. Chief Financial Officer Dartmouth Hitchcock 6036508136	3/20/2018 2:57 PM
Details	Last Recertification Date	Update	Recertification	2/1/2017 12:00:00 AM	2/9/2018 3:30:36 PM	2/9/2018 3:30 PM
Details	Grant Number	Update	Change Request	H12HA24881	H12HA31112	11/7/2017 11:08 AM
Contacts	Authorizing Official	Update		Siepka, Thomas J. CHIEF PHARMACY OFFICER 6036505738	Siepka, Thomas J. CHIEF PHARMACY OFFICER Dartmouth-Hitchcock 6036505738	10/10/2017 9:23 AM
Contacts	Primary Contact	Update	Profile Change Request	Lessard, Michael Director of System Pharmacy Operations Mary Hitchcock 6036532387	Lessard, Michael Director of System Pharmacy Operations Dartmouth Hitchcock 6036532387	9/19/2017 7:51 AM
Contacts	Primary Contact	Update		Lessard, Michael Director of System Pharmacy Operations 6036532387	Lessard, Michael Director of System Pharmacy Operations Mary Hitchcock 6036532387	9/19/2017 7:48 AM
Contacts	Authorizing Official	Insert			Siepka, Thomas J. CHIEF PHARMACY OFFICER 6036505738	7/20/2017 12:53 PM
Contacts	Primary Contact	Update		Merchant, Gary Manager Regional Pharmacy 6036532380	Lessard, Michael Director of System Pharmacy Operations 6036532387	2/1/2017 1:15 PM
Contacts	Signed By	Insert			Kilfeather-Mackey, Robin Chief Financial Officer 6036504466	2/1/2017 1:15 PM
Addresses	Main Address	Insert			100 Hitchcock Way Manchester, NH 03104	2/1/2017 1:10 PM
Details	Last Recertification Date	Update			2/1/2017 12:00:00 AM	2/1/2017 1:10 PM
Addresses	Billing Address	Insert			Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon, NH 03756-0001	7/21/2016 10:09 AM
Addresses	Shipping Address	Insert			Mary Hitchcock Memorial Hospital One Medical Center Drive Lebanon, NH 03756-0001	7/21/2016 10:09 AM
Contacts	Primary Contact	Insert			Merchant, Gary Manager Regional Pharmacy 6036532380	7/21/2016 8:26 AM
Dates	Participating Approval Date	Update			4/21/2016 12:00:00 AM	4/21/2016 5:58 PM
Details	State	Update		Pending	Active	4/21/2016 5:58 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/21/2016 5:58 PM
Details	340B ID	Update		RW424882	RW424881A	4/21/2016 1:46 PM
Details	340B ID	Update		ONLINE_REG_59982	RW424882	4/21/2016 1:43 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_59982	4/13/2016 11:11 AM
Details	Last Recertification Date	Insert				4/13/2016 11:11 AM
Details	Grant Number	Insert			H12HA24881	4/13/2016 11:11 AM
Details	340B ID	Insert			ONLINE_REG	4/13/2016 11:11 AM
Details	Is Authorizing Official EHB Data	Insert				4/13/2016 11:11 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/13/2016 11:11 AM
Details	Medicare Provider Number	Insert				4/13/2016 11:11 AM
Details	Entity Name	Insert			Mary Hitchcock Memorial Hospital dba Ryan White Program	4/13/2016 11:11 AM
Details	Program Code	Insert			RW4	4/13/2016 11:11 AM
Details	Entity Subname	Insert			Dartmouth-Hitchcock Manchester, Ryan White Part D	4/13/2016 11:11 AM
Dates	Participating Approval Date	Insert				4/13/2016 11:11 AM
Details	State	Insert			Pending	4/13/2016 11:11 AM
Dates	Registration Date	Insert			4/13/2016 12:00:00 AM	4/13/2016 11:11 AM
Dates	Signed By Date	Insert			4/13/2016 12:00:00 AM	4/13/2016 11:11 AM
Dates	Start Date	Insert				4/13/2016 11:11 AM
Terminations	Termination Comments	Insert				4/13/2016 11:11 AM
Terminations	Termination Date	Insert				4/13/2016 11:11 AM
Terminations	Termination Effective Date	Insert				4/13/2016 11:11 AM
Terminations	Termination Reason	Insert				4/13/2016 11:11 AM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History