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MAXI GREEN, INC.
CAH471303-00 NORTHEASTERN VERMONT REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
NORTHEASTERN VERMONT REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH471303-00
Entity Address
1315 HOSPITAL DRIVE
ST JOHNSBURY, VT 05819
Medicare Provider Number
471303
Participating Start Date
9/28/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10335
502 RAILROAD STREET
ST. JOHNSBURY, VT 05819
Pharmacy Comments
Contract Details
Approval Date
9/19/2012
Contract Begin Date
10/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2018
Ownership change
Contacts
Covered Entity Signing Official
Robert Hersey, CFO
(802) 748-7530
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
8/28/2012
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