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CVS MANCHESTER NH, L.L.C.
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
CVS MANCHESTER NH, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02257
250 MAMMOTH ROAD
MANCHESTER, NH 03109
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Keith B Thomasset, Chief Pharmacy Officer
(603) 656-0966
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2025
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