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GENOA HEALTHCARE LLC
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
GENOA HEALTHCARE LLC
Pharmacy Address
72 HARREL ST STE A03
MORRISVILLE, VT 05661
Pharmacy Comments
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
Optum Pharmacy
Nancy McCutcheon, Sr. VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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