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DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
CAH301305-04 ALICE PECK DAY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ALICE PECK DAY MEMORIAL HOSPITAL
Subdivision Name
MSC Orthopaedics - Orthopaedic Clinic
Type
Critical Access Hospital
340B ID
CAH301305-04
Entity Address
9 Alice Peck Day Drive
Lebanon, NH 03766
Medicare Provider Number
301305
Outpatient Facility Provider Number
Participating Start Date
4/1/2020
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
Pharmacy Address
12 CENTERRA PKWY STE 10
LEBANON, NH 03766
Pharmacy Comments
Contract Details
Approval Date
1/3/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Todd P Roberts, CFO
(603) 308-0082
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/3/2020
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