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DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
CAH471301-11 GIFFORD MEDICAL CENTER
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Covered Entity Details
Entity Name
GIFFORD MEDICAL CENTER
Subdivision Name
TWIN RIVER HEALTH CENTER - GENERAL SURGERY CLINIC (UROLOGY)
Type
Critical Access Hospital
340B ID
CAH471301-11
Entity Address
108 NORTH MAIN ST
WHITE RIVER JUNCTION, VT 05001
Medicare Provider Number
471301
Outpatient Facility Provider Number
Participating Start Date
7/1/2011
Last Recertification Date
9/19/2022
Entity Termination Date
10/1/2023
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
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel Bennett, CEO
(802) 728-2304
Contract Pharmacy Representative
Mary Hitchcock Memorial Hospital
Curtis A. Gibbon, Director - Retail Pharmacy
(603) 308-2287
Signed By Date
10/12/2020
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