Contract Pharmacy Details

MAXI DRUG NORTH, INC.
CAH301310-00 ANDROSCOGGIN VALLEY HOSPITAL , Inc.

Covered Entity Details

Entity Name

ANDROSCOGGIN VALLEY HOSPITAL , Inc.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH301310-00

Entity Address

59 PAGE HILL ROAD
BERLIN, NH 03570-3542

Medicare Provider Number

301310

Participating Start Date

9/29/2010

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

MAXI DRUG NORTH, INC.

Pharmacy Address

RITE AID #10287
200 PLEASANT STREET
BERLIN, NH 03570

Pharmacy Comments

Contract Details

Approval Date

12/31/2012

Contract Begin Date

1/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/25/2018
Ownership change

Contacts

Covered Entity Signing Official

RUSSELL KEENE, CEO
(603) 752-2200

Contract Pharmacy Representative

Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217

Signed By Date

12/18/2012

340B Drug Pricing Program Database