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RW431112B 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
Dartmouth-Hitchcock Manchester, Ryan White Part D
Type
Ryan White Part D
340B ID
RW431112B
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
2/28/2022
Time Period the Assistance was Received
8/1/2017 - 7/31/2023
Termination Date
Termination Reason
4/1/2023
Site closure
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
100 Hitchcock Way
Manchester, NH 03104
Billing Address
Mary Hitchcock Memorial Hospital
One Medical Center Drive
Lebanon, NH 03756
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
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