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MAXI DRUG NORTH, INC.
RW431112D 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 D
Type
Ryan White Part D
340B ID
RW431112D
Entity Address
580 Court Street
Keene, NH 03431
Grant Number
H12HA31112
Participating Start Date
1/1/2023
Last Recertification Date
2/5/2024
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
MAXI DRUG NORTH, INC.
Pharmacy Address
RITE AID #10267
123 NASHUA ROAD
LONDONDERRY, NH 03053
Pharmacy Comments
Contract Details
Approval Date
4/10/2023
Contract Begin Date
4/25/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2023
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
4/10/2023
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