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HANNAFORD BROS. CO., LLC
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
HANNAFORD BROS. CO., LLC
Pharmacy Address
DBA HANNAFORD SUPERMARKET & PHARMACY #83
952 CENTRAL ST
FRANKLIN, NH 03235
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Staci A Hermann, CHIEF PHARMACY OFFICER
(603) 653-3160
Contract Pharmacy Representative
Hannaford Supermarket and Pharmacy
Daniel Montagnola, Business Development Manager
(315) 427-5178
Signed By Date
1/12/2024
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