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MAXI GREEN, INC.
SCH470024-00 Northwestern Medical Center, Inc.
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Covered Entity Details
Entity Name
Northwestern Medical Center, Inc.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH470024-00
Entity Address
133 Fairfield Street
St. Albans, VT 05478
Medicare Provider Number
470024
Participating Start Date
1/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10325
133 NORTH MAIN STREET SUITE 23
ST. ALBANS, VT 05478
Pharmacy Comments
Contract Details
Approval Date
4/8/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/26/2018
Ownership change
Contacts
Covered Entity Signing Official
Ted Sirotta, CFO
(802) 524-1042
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/8/2013
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