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VANDERBILT HEALTH PHARMACY GROUP
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC300003-00
Entity Address
ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
9/28/2010
Last Recertification Date
9/15/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
VANDERBILT HEALTH PHARMACY GROUP
Pharmacy Address
718 MELROSE AVE
NASHVILLE, TN 37211-3721
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/5/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Vanderbilt Health Pharmacy Group
James R Manfred, Executive Director, VHPG
(615) 322-4775
Signed By Date
4/15/2019
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