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GENOA HEALTHCARE LLC
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
GENOA HEALTHCARE LLC
Pharmacy Address
72 HARREL ST STE A03
MORRISVILLE, VT 05661
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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