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DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC300003-00
Entity Address
ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
9/28/2010
Last Recertification Date
9/15/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
Pharmacy Address
12 CENTERRA PKWY STE 10
LEBANON, NH 03766
Pharmacy Comments
Contract Details
Approval Date
5/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Daniel P. Jantzen, Chief Financial Officer
(603) 650-8136
Contract Pharmacy Representative
Dartmouth-Hitchcock Health
Linda M Sawyer, Sr Director Pharmacy Retail and Specialty Pharmacy
(603) 308-2282
Signed By Date
5/6/2018
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