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WALGREEN EASTERN CO., INC.
HV00812A 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
Dartmouth-Hitchcock Manchester, Ryan White Part C
Type
Ryan White Part C
340B ID
HV00812A
Entity Address
100 Hitchcock Way
Manchester, NH 03104
Grant Number
H76HA31654
Participating Start Date
7/1/2016
Last Recertification Date
2/28/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: RITE AID #04139
1623 WHITE MOUNTAIN HIGHWAY
NORTH CONWAY, NH 03860
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
6/12/2018
Pharmacy closed
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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