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RITE AID OF NEW HAMPSHIRE, INC.
RW431112B 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 D
Type
Ryan White Part D
340B ID
RW431112B
Entity Address
100 Hitchcock Way
Manchester, NH 03104
Grant Number
H12HA31112
Participating Start Date
1/1/2019
Last Recertification Date
2/28/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
RITE AID OF NEW HAMPSHIRE, INC.
Pharmacy Address
RITE AID #4741
1631 ELM STREET
MANCHESTER, NH 03101
Pharmacy Comments
Contract Details
Approval Date
12/14/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
12/14/2018
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