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RRC300003-03 MARY HITCHCOCK MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Dartmouth-Hitchcock Heater Road
Type
Rural Referral Center
Rural
Yes
340B ID
RRC300003-03
Medicare Provider Number
300003
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
7/10/2013
Participating Start Date
10/1/2013
Participating Approval Date
8/6/2013
Last Recertification Date
8/20/2019
Termination Date
Termination Reason
7/1/2020
Other
Contacts
Authorizing Official
Dartmouth-Hitchcock
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Primary Contact
Dartmouth-Hitchcock
Tyler Dean Wilson, 340B Analyst
(603) 653-2347
Addresses
Street Address
18 Old Etna Road
Lebanon, NH 03766
Billing Address
Mary Hitchcock Memorial Hospital
One Medical Center Drive
Lebanon, NH 03756-0001
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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