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DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
HV00812D 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 C
Type
Ryan White Part C
340B ID
HV00812D
Entity Address
580 Court Street
Keene, NH 03431
Grant Number
H76HA31654
Participating Start Date
1/1/2023
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
DARTMOUTH-HITCHCOCK PHARMACY AT CENTERRA
Pharmacy Address
12 CENTERRA PKWY STE 10
LEBANON, NH 03766
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Patrick F. Jordan, Chief Operating Officier
(603) 650-5706
Contract Pharmacy Representative
Dartmouth-Hitchcock
Patrick F. Jordan, Chief Operating Officier
(603) 650-5706
Signed By Date
4/15/2024
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