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MAXI GREEN, 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
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10313
55 SPRINGFIELD PLAZA RD
SPRINGFIELD, VT 05156-2911
Pharmacy Comments
Contract Details
Approval Date
4/20/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/15/2025
Business decision by covered entity and/or pharmacy
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
4/15/2022
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