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VICTORY DISTRIBUTORS, LLC
DSH220063 THE LOWELL GENERAL HOSPITAL
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Covered Entity Details
Entity Name
THE LOWELL GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220063
Entity Address
295 VARNUM AVENUE
LOWELL, MA 01854
Medicare Provider Number
220063
Participating Start Date
4/1/2004
Last Recertification Date
9/12/2024
Pharmacy Details
Pharmacy Name
VICTORY DISTRIBUTORS, LLC
Pharmacy Address
DBA HANNAFORD SUPERMARKET & PHARMACY 819
301 PLEASANT ST
DRACUT, MA 01826
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William F Wyman, SVP of Operations & Treasurer
(978) 937-6034
Contract Pharmacy Representative
Hannaford Bros. Co., LLc
Deanne Sargent, Manager Pharmacy Network & Buisness Development
(207) 885-3044
Signed By Date
10/13/2020
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