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FIRST COLONY CORP
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
FIRST COLONY CORP
Pharmacy Address
DBA: COLONIAL PHARMACY
PO BOX 10
82 NEWPORT RD
NEW LONDON, NH 03257
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas J. Siepka, CHIEF PHARMACY OFFICER
(603) 650-5738
Contract Pharmacy Representative
Independent Pharmacy
Glenn Perreault, Owner
(603) 526-2233
Signed By Date
10/17/2016
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