Contract Pharmacy Details

CVS MANCHESTER NH, L.L.C.
RW431112C Mary Hitchcock Memorial Hospital dba Ryan White Program

Covered Entity Details

Entity Name

Mary Hitchcock Memorial Hospital dba Ryan White Program

Subdivision Name

Bedford Clinic, Ryan White Part D

Type

Ryan White Part D

340B ID

RW431112C

Entity Address

5 Washington Place
Bedford, NH 03110

Grant Number

H12HA31112

Participating Start Date

1/1/2019

Last Recertification Date

2/5/2024

Entity Termination Date

10/1/2024

Pharmacy Details

Pharmacy Name

CVS MANCHESTER NH, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 00647
250 PLAINFIELD RD.
UPPER VALLEY PLAZA
WEST LEBANON, NH 03784

Pharmacy Comments

Contract Details

Approval Date

10/21/2022

Contract Begin Date

10/25/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2024
Covered Entity Terminated

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

10/21/2022

340B Drug Pricing Program Database