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KPH HEALTHCARE SERVICES, INC.
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC300003-00
Entity Address
ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
9/28/2010
Last Recertification Date
9/15/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
KPH HEALTHCARE SERVICES, INC.
Pharmacy Address
KINNEY DRUGS #102
151 VT ROUTE 12 S
RANDOLPH, VT 05060-9237
Pharmacy Comments
Contract Details
Approval Date
1/27/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Robin Kilfeather-Mackey, Chief Financial Officer
(603) 650-4466
Contract Pharmacy Representative
Kinney Drugs
Debbi Barber, Director of Pharmacy Programs
(315) 287-3600 Ext: 2423
Signed By Date
1/27/2016
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