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MAXI DRUG NORTH, INC.
DSH220016 BAYSTATE FRANKLIN MEDICAL CENTER
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Covered Entity Details
Entity Name
BAYSTATE FRANKLIN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220016
Entity Address
164 HIGH STREET
GREENFIELD, MA 01301
Medicare Provider Number
220016
Participating Start Date
4/1/2009
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
MAXI DRUG NORTH, INC.
Pharmacy Address
RITE AID #10300
105 MILTON ROAD
ROCHESTER, NH 03868
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chuck Gijanto, President
(413) 773-2611
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
1/15/2014
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