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RITE AID OF NEW HAMPSHIRE, INC.
HV00812 Mary Hitchcock Memorial Hospital dba Ryan White Program
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Covered Entity Details
Entity Name
Mary Hitchcock Memorial Hospital dba Ryan White Program
Subdivision Name
Ryan White Part C
Type
Ryan White Part C
340B ID
HV00812
Entity Address
One Medical Center Drive
Lebanon, NH 03756
Grant Number
H76HA31654
Participating Start Date
1/1/2015
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
RITE AID OF NEW HAMPSHIRE, INC.
Pharmacy Address
RITE AID #4166
360 SUMMER STREET
BRISTOL, NH 03222
Pharmacy Comments
Contract Details
Approval Date
1/10/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Rite Aid
Charlene Kaiser, VP, Managed Care Operations
(918) 645-6652
Signed By Date
1/10/2023
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