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MAXI DRUG NORTH, INC.
HV00812 Mary Hitchcock Memorial Hospital dba Ryan White Program
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Covered Entity Details
Entity Name
Mary Hitchcock Memorial Hospital dba Ryan White Program
Subdivision Name
Ryan White Part C
Type
Ryan White Part C
340B ID
HV00812
Entity Address
One Medical Center Drive
Lebanon, NH 03756
Grant Number
H76HA31654
Participating Start Date
1/1/2015
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
MAXI DRUG NORTH, INC.
Pharmacy Address
RITE AID #10278
270 MAMMOTH ROAD
MANCHESTER, NH 03109
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robin Kilfeather-Mackey, Chief Financial Officer
(603) 650-4466
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/14/2014
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