Contract Pharmacy Details

MAXI GREEN, INC.
DSH470003 UNIVERSITY OF VERMONT MEDICAL CENTER

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 #10318
39 HINESBURG ROAD
SOUTH BURLINGTON, VT 05403

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

340B Drug Pricing Program Database