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MAXI DRUG NORTH, 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
MAXI DRUG NORTH, INC.
Pharmacy Address
RITE AID #10270
331 MAIN STREET
NASHUA, NH 03060
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
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
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
7/17/2018
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