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WALGREEN EASTERN CO., INC.
RW424881 Mary Hitchcock Memorial Hospital dba Ryan White Program
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Covered Entity Details
Entity Name
Mary Hitchcock Memorial Hospital dba Ryan White Program
Subdivision Name
Ryan White Part D
Type
Ryan White Part D
340B ID
RW424881
Entity Address
One Medical Center Drive
Lebanon, NH 03756
Grant Number
H12HA31112
Participating Start Date
1/1/2018
Last Recertification Date
2/9/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
WALGREENS #18354
621 ROUTE 22A N
FAIR HAVEN, VT 05743
Pharmacy Comments
Contract Details
Approval Date
5/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel P. Jantzen, Chief Financial Officer
(603) 650-8136
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
5/16/2018
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