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CVS MANCHESTER NH, L.L.C.
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
CVS MANCHESTER NH, L.L.C.
Pharmacy Address
CVS/PHARMACY #17827
200 SOUTH MAIN STREET, UNIT 24
WEST LEBANON, NH 03784
Pharmacy Comments
Contract Details
Approval Date
10/6/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/6/2022
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