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RW424881C 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
D-H Specialty Care at Bedford Medical Park, Ryan White Part D
Type
Ryan White Part D
340B ID
RW424881C
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
5 Washington Place
Bedford, NH 03110
Billing Address
Mary Hitchcock Memorial Hospital
One Medical Center Drive
Lebanon, NH 03756-0001
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.
12/13/2018
April 2025
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