Contract Pharmacy Details

CVS MANCHESTER NH, L.L.C.
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL

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

CVS MANCHESTER NH, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 00650
1351 WHITE MOUNTAIN HWY
NORTHWAY SHPGPLZ
NORTH CONWAY, NH 03860

Pharmacy Comments

Contract Details

Approval Date

10/13/2021

Contract Begin Date

1/1/2022

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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

10/13/2021

340B Drug Pricing Program Database