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RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
Rural
Yes
340B ID
RRC300003-00
Medicare Provider Number
300003
Additional Details
Current Program Status
Terminated
Registration Date
9/22/2010
Participating Start Date
9/28/2010
Participating Approval Date
9/24/2010
Last Recertification Date
9/15/2021
Termination Date
Termination Reason
7/1/2022
Change of covered entity type
Contacts
Authorizing Official
Dartmouth-Hitchcock
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Primary Contact
Dartmouth-Hitchcock
Kristin A Chupka, Director - Pharmacy System 340B Program
(603) 656-0945
Addresses
Street Address
ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/1/11 ADDED SHIP-TO ADD
03/01/2011
April 2025
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