Covered Entity Details

CAH301305-04 ALICE PECK DAY MEMORIAL HOSPITAL (Active) - information as of 5/23/2025 10:25:13 PM

Main Details

Name

ALICE PECK DAY MEMORIAL HOSPITAL

Subdivision Name

MSC Orthopaedics - Orthopaedic Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH301305-04

Medicare Provider Number

301305

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

1/2/2020

Participating Start Date

4/1/2020

Participating Approval Date

1/3/2020

Last Recertification Date

8/14/2024

Contacts

Authorizing Official

Alice Peck Day Memorial Hospital
Paula Seaman, CNO
(603) 308-0089

Primary Contact

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

Addresses

Street Address

9 Alice Peck Day Drive
Lebanon, NH 03766

Billing Address

Alice Peck Day Memorial Hospital
10 Alice Peck Day Drive
Lebanon, NH 03766

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

Alice Peck Day Memorial Hospital
10 Alice Peck Day Drive
Lebanon, NH 03766

Shipping Address 2

Alice Peck Day Memorial Hospital
1000 Quality Drive
Hooksett, NH 03106

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA	12 CENTERRA PKWY STE 10		LEBANON	NH	03766	01/03/2020	04/01/2020	01/13/2022	01/13/2022
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS # 09177	3 AIRPORT RD	WEST LEBANON	NH	03784	01/03/2020	04/01/2020	01/13/2022	01/13/2022
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	01/03/2020	04/01/2020	01/13/2022	01/13/2022
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	01/03/2020	04/01/2020	01/13/2022	01/13/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH301305-01	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	NEUROSURGERY SERVICE AT ALICE PECK DAY HOSPITAL	5 Alice Peck Day Drive	LEBANON	NH	Active
CAH301305-04	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC Orthopaedics - Orthopaedic Clinic	9 Alice Peck Day Drive	Lebanon	NH	Active
CAH301305-05	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC General Surgery - General Surgery Clinic	9 Alice Peck Day Drive	Lebanon	NH	Active
CAH301305-06	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC Women's Care - OB/GYN	9 Alice Peck Day Drive	Lebanon	NH	Active
CAH301305-07	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC Pain Clinic - Pain Management Services	9 Alice Peck Day Drive	Lebanon	NH	Active
CAH301305-08	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC Primary Care - Primary Care	9 Alice Peck Day Drive	Lebanon	NH	Active
CAH301305-09	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	Occupational Medicine - Occupational Medicine	9 Alice Peck Day Drive	Lebanon	NH	Terminated
CAH301305-10	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	ALICE PECK DAY MEMORIAL HOSPITAL - Sleep Health	5 ALICE PECK DAY DR	LEBANON	NH	Active
CAH301305-11	Child	CAH	ALICE PECK DAY MEMORIAL HOSPITAL	MSC Infusion Clinic - Infusion	9 Alice Peck Day Drive	Lebanon	NH	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Change Request	Roberts, Todd P CFO Alice Peck Day Memorial Hospital 6033080082	Seaman, Paula CNO Alice Peck Day Memorial Hospital 6033080089	4/14/2025 12:02 PM
Addresses	Shipping Address	Delete	Group Change Request	Alice Peck Day Memorial Hospital 12 Centerra Parkway, Suite 10 Lebanon, NH 03766		4/11/2025 8:16 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 10:07:05 AM	8/14/2024 9:43:38 AM	8/14/2024 9:43 AM
Contacts	Authorizing Official	Update	Profile Change Request	Roberts, Todd P VP Finance Alice Peck Day Memorial Hospital 6034425997	Roberts, Todd P CFO Alice Peck Day Memorial Hospital 6033080082	7/15/2024 11:10 AM
Contacts	Signed By	Update	Profile Change Request	Roberts, Todd P VP Finance Alice Peck Day Memorial Hospital 6034425997	Roberts, Todd P CFO Alice Peck Day Memorial Hospital 6033080082	7/15/2024 11:10 AM
Details	Last Recertification Date	Update	Recertification	9/14/2022 12:51:10 PM	8/15/2023 10:07:05 AM	8/15/2023 10:07 AM
Addresses	Shipping Address	Insert	Change Request		Alice Peck Day Memorial Hospital 1000 Quality Drive Hooksett, NH 03106	3/16/2023 11:01 AM
Addresses	Shipping Address	Insert	Change Request		Alice Peck Day Memorial Hospital 12 Centerra Parkway, Suite 10 Lebanon, NH 03766	3/16/2023 11:01 AM
Contacts	Primary Contact	Update	Profile Change Request	Chupka, Kristin A Director - Pharmacy System 340B Program Dartmouth-Hitchcock 6036532387	Chupka, Kristin A Director - Pharmacy System 340B Program Dartmouth-Hitchcock 6036560945	10/21/2022 10:25 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 12:36:11 PM	9/14/2022 12:51:10 PM	9/14/2022 12:51 PM
Details	Last Recertification Date	Update	Recertification	8/17/2020 9:18:10 AM	8/27/2021 12:36:11 PM	8/27/2021 12:36 PM
Contacts	Primary Contact	Update	Change Request	Chan, Suzy D. Pharmacy Manager Alice Peck Day 6034487404	Chupka, Kristin A Director - Pharmacy System 340B Program Dartmouth-Hitchcock 6036532387	6/10/2021 11:52 AM
Contacts	Authorizing Official	Update	Profile Change Request	Roberts, Todd P Director of Fiscal Services Alice Peck Day Memorial Hospital 6034425997	Roberts, Todd P VP Finance Alice Peck Day Memorial Hospital 6034425997	8/17/2020 9:51 AM
Contacts	Signed By	Update	Profile Change Request	Roberts, Todd P Director of Fiscal Services Alice Peck Day Memorial Hospital 6034425997	Roberts, Todd P VP Finance Alice Peck Day Memorial Hospital 6034425997	8/17/2020 9:51 AM
Contacts	Primary Contact	Update	Profile Change Request	Chan, Suzy D. Interim Pharmacy Manager Alice Peck Day 6034487404	Chan, Suzy D. Pharmacy Manager Alice Peck Day 6034487404	8/17/2020 9:23 AM
Details	Last Recertification Date	Update	Recertification		8/17/2020 9:18:10 AM	8/17/2020 9:18 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Roberts, Todd P Director of Fiscal Services Alice Peck Day Memorial Hospital 6034425997	1/3/2020 7:21 AM
Details	340B ID	Update	New Registration		CAH301305-04	1/3/2020 7:21 AM
Details	Entity Subname	Update	New Registration	MSC Orthopaedics	MSC Orthopaedics - Orthopaedic Clinic	1/3/2020 7:21 AM
Dates	Participating Approval Date	Update	New Registration		1/3/2020 7:21:23 AM	1/3/2020 7:21 AM
Details	State	Update	New Registration	Pending	Approved	1/3/2020 7:21 AM
Dates	Signed By Date	Update	New Registration		1/2/2020 3:03:00 PM	1/3/2020 7:21 AM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	1/3/2020 7:21 AM
Addresses	Main Address	Insert	New Registration		9 Alice Peck Day Drive Lebanon, NH 03766	1/2/2020 2:04 PM
Addresses	Billing Address	Insert	New Registration		Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon, NH 03766	1/2/2020 2:04 PM
Addresses	Shipping Address	Insert	New Registration		Alice Peck Day Memorial Hospital 10 Alice Peck Day Drive Lebanon, NH 03766	1/2/2020 2:04 PM
Contacts	Primary Contact	Insert	New Registration		Chan, Suzy D. Interim Pharmacy Manager Alice Peck Day 6034487404	1/2/2020 2:04 PM
Contacts	Authorizing Official	Insert	New Registration		Roberts, Todd P Director of Fiscal Services Alice Peck Day Memorial Hospital 6034425997	1/2/2020 2:04 PM
Details	Last Recertification Date	Insert	New Registration			1/2/2020 2:04 PM
Details	Grant Number	Insert	New Registration			1/2/2020 2:04 PM
Details	340B ID	Insert	New Registration			1/2/2020 2:04 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/2/2020 2:04 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/2/2020 2:04 PM
Details	Medicare Provider Number	Insert	New Registration		301305	1/2/2020 2:04 PM
Details	Entity Name	Insert	New Registration		ALICE PECK DAY MEMORIAL HOSPITAL	1/2/2020 2:04 PM
Details	Program Code	Insert	New Registration		CAH	1/2/2020 2:04 PM
Details	Entity Subname	Insert	New Registration		MSC Orthopaedics	1/2/2020 2:04 PM
Dates	Participating Approval Date	Insert	New Registration			1/2/2020 2:04 PM
Details	State	Insert	New Registration		Pending	1/2/2020 2:04 PM
Dates	Registration Date	Insert	New Registration		1/2/2020 2:04:54 PM	1/2/2020 2:04 PM
Dates	Signed By Date	Insert	New Registration			1/2/2020 2:04 PM
Dates	Start Date	Insert	New Registration			1/2/2020 2:04 PM
Terminations	Termination Comments	Insert	New Registration			1/2/2020 2:04 PM
Terminations	Termination Date	Insert	New Registration			1/2/2020 2:04 PM
Terminations	Termination Effective Date	Insert	New Registration			1/2/2020 2:04 PM
Terminations	Termination Reason	Insert	New Registration			1/2/2020 2:04 PM