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MAXI GREEN, INC.
DSH470005 RUTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
RUTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470005
Entity Address
160 ALLEN STREET
RUTLAND, VT 05701
Medicare Provider Number
470005
Participating Start Date
7/1/2016
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10312
213 MAIN STREET
LUDLOW, VT 05149
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/16/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Judi K Fox, CFO
(802) 747-1632
Contract Pharmacy Representative
Rite Aid Pharmacy
Christopher Moen, VP, Strategic Pharmacy Relations
(717) 791-3129
Signed By Date
10/14/2022
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