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WALGREEN EASTERN CO., INC.
RW431112A 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
RW431112A
Entity Address
One Medical Center Drive
Lebanon, NH 03756
Grant Number
H12HA31112
Participating Start Date
1/1/2019
Last Recertification Date
2/5/2024
Entity Termination Date
10/1/2024
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
12/14/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/12/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
12/14/2018
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