Contract Pharmacy Details

DARTMOUTH-HITCHCOCK PHARMACY
HV00812A Mary Hitchcock Memorial Hospital dba Ryan White Program

Covered Entity Details

Entity Name

Mary Hitchcock Memorial Hospital dba Ryan White Program

Subdivision Name

Dartmouth-Hitchcock Manchester, Ryan White Part C

Type

Ryan White Part C

340B ID

HV00812A

Entity Address

100 Hitchcock Way
Manchester, NH 03104

Grant Number

H76HA31654

Participating Start Date

7/1/2016

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

340B Drug Pricing Program Database