Contract Pharmacy Details

MAXI DRUG NORTH, INC.
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

MAXI DRUG NORTH, INC.

Pharmacy Address

RITE AID #10293
865 CENTRAL AVENUE
DOVER, NH 03820

Pharmacy Comments

Contract Details

Approval Date

1/11/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/22/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160

Contract Pharmacy Representative

Rite Aid
Charlene Kaiser, VP, Managed Care Operations
(918) 645-6652

Signed By Date

1/11/2022

340B Drug Pricing Program Database