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VICTORY DISTRIBUTORS, LLC
RRC300019-00 CHESHIRE MEDICAL CENTER
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Covered Entity Details
Entity Name
CHESHIRE MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC300019-00
Entity Address
580 COURT STREET
KEENE, NH 03431
Medicare Provider Number
300019
Participating Start Date
7/1/2023
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
VICTORY DISTRIBUTORS, LLC
Pharmacy Address
DBA HANNAFORD SUPERMARKET & PHARMACY #81
201 JOHN DEVINE DR
MANCHESTER, NH 03103
Pharmacy Comments
Contract Details
Approval Date
5/2/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/6/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kathryn Willbarger, COO
(603) 354-5488
Contract Pharmacy Representative
Hannaford
Dan Fadden, 340B Program Manager
(845) 392-8959
Signed By Date
4/18/2023
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