Contract Pharmacy Details

MAXI DRUG NORTH, INC.
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

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

340B Drug Pricing Program Database