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RW431112A 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
RW431112A
Grant Number
H12HA31112
Additional Details
Current Program Status
Terminated
Registration Date
12/13/2018
Participating Start Date
1/1/2019
Participating Approval Date
12/14/2018
Last Recertification Date
2/5/2024
Time Period the Assistance was Received
8/1/2022 - 7/31/2026
Termination Date
Termination Reason
10/1/2024
Other
Contacts
Authorizing Official
Dartmouth-Hitchcock
Patrick F. Jordan, Chief Operating Officier
(603) 650-5706
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
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.
12/14/2018
April 2025
April 2025
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