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PRICE CHOPPER OPERATING CO NEW HAMPSHIRE
DSH300003 MARY HITCHCOCK MEMORIAL HOSP
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH300003
Entity Address
One Medical Center Drive
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
PRICE CHOPPER OPERATING CO NEW HAMPSHIRE
Pharmacy Address
PRICE CHOPPER PHARMACY 227
370 MIRACLE MILE ROAD
LEBANON, NH 03766-2635
Pharmacy Comments
Contract Details
Approval Date
10/18/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/18/2024
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
Northeast Shared Services
Scott Guisinger, Vice President of Pharmacy
(518) 379-2409
Signed By Date
10/18/2023
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