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MAXI DRUG NORTH, INC.
RW431112C 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
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
MAXI DRUG NORTH, INC.
Pharmacy Address
RITE AID #10298
31 GARDEN ROAD
PLAISTOW, NH 03865
Pharmacy Comments
Contract Details
Approval Date
1/16/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/22/2023
Pharmacy closed
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
1/16/2023
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