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MAXI GREEN, INC.
DSH470003 UNIVERSITY OF VERMONT MEDICAL CENTER
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Covered Entity Details
Entity Name
UNIVERSITY OF VERMONT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470003
Entity Address
111 Colchester Avenue
Burlington, VT 05401
Medicare Provider Number
470003
Participating Start Date
4/1/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10324
201 US ROUTE 7 SOUTH
PO BOX 31
MILTON, VT 05468
Pharmacy Comments
Contract Details
Approval Date
10/24/2012
Contract Begin Date
10/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2018
Ownership change
Contacts
Covered Entity Signing Official
Roger Deshaies, CFO
(802) 847-9975
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
9/28/2012
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