Contract Pharmacy Details

MAXI GREEN, INC.
CAH301305-00 ALICE PECK DAY MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

ALICE PECK DAY MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH301305-00

Entity Address

10 ALICE PECK DAY DRIVE
LEBANON, NH 03766

Medicare Provider Number

301305

Participating Start Date

4/1/2020

Last Recertification Date

8/14/2024

Pharmacy Details

Pharmacy Name

MAXI GREEN, INC.

Pharmacy Address

RITE AID #10313
55 SPRINGFIELD PLAZA RD
SPRINGFIELD, VT 05156-2911

Pharmacy Comments

Contract Details

Approval Date

7/9/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/31/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Todd P Roberts, CFO
(603) 308-0082

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

7/9/2020

340B Drug Pricing Program Database