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KPH HEALTHCARE SERVICES, INC.
DSH300003 MARY HITCHCOCK MEMORIAL HOSP
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH300003
Entity Address
One Medical Center Drive
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #58
55 SHATTUCK HILL ROAD
NEWPORT, VT 05855
Pharmacy Comments
04/12/2012 address correction (was 55 Shattuck Hilld Rd.)
Contract Details
Approval Date
4/20/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
KPH Healthcare Services, Inc.
Debbi Barber, 340B Program Director
(315) 287-3600 Ext: 2423
Signed By Date
4/15/2022
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