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DARTMOUTH-HITCHCOCK PHARMACY
RW431112B Mary Hitchcock Memorial Hospital dba Ryan White Program
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Covered Entity Details
Entity Name
Mary Hitchcock Memorial Hospital dba Ryan White Program
Subdivision Name
Dartmouth-Hitchcock Manchester, Ryan White Part D
Type
Ryan White Part D
340B ID
RW431112B
Entity Address
100 Hitchcock Way
Manchester, NH 03104
Grant Number
H12HA31112
Participating Start Date
1/1/2019
Last Recertification Date
2/28/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
DARTMOUTH-HITCHCOCK PHARMACY
Pharmacy Address
1000 QUALITY DR
HOOKSETT, NH 03106
Pharmacy Comments
Contract Details
Approval Date
8/19/2022
Contract Begin Date
8/22/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Dartmouth-Hitchcock
Patrick F. Jordan, Chief Operating Officier
(603) 650-5706
Signed By Date
8/19/2022
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