Contract Pharmacy Details

MAXI DRUG NORTH, INC.
HV00812D Mary Hitchcock Memorial Hospital dba Ryan White Program

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

HV00812D

Entity Address

580 Court Street
Keene, NH 03431

Grant Number

H76HA31654

Participating Start Date

1/1/2023

Last Recertification Date

2/14/2025

Pharmacy Details

Pharmacy Name

MAXI DRUG NORTH, INC.

Pharmacy Address

RITE AID #10278
270 MAMMOTH ROAD
MANCHESTER, NH 03109

Pharmacy Comments

Contract Details

Approval Date

1/11/2023

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

1/11/2023

340B Drug Pricing Program Database