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RW424881 Mary Hitchcock Memorial Hospital dba Ryan White Program (Terminated)
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Main Details
Name
Mary Hitchcock Memorial Hospital dba Ryan White Program
Subdivision Name
Ryan White Part D
Type
Ryan White Part D
340B ID
RW424881
Grant Number
H12HA31112
Additional Details
Current Program Status
Terminated
Registration Date
10/16/2017
Participating Start Date
1/1/2018
Participating Approval Date
10/24/2017
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
One Medical Center Drive
Lebanon, NH 03756
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
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Based on documentation provided by the entity, OPA determined that the contract pharmacies were eligible back to January 1, 2018.
12/11/2018
Participating from effective date (01/01/2015) until terminated effective date (10/15/2017), reinstatement effective date (01/01/2018)
10/19/2017
April 2025
April 2025
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