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RITE AID OF VERMONT, INC.
RW424881 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 D
Type
Ryan White Part D
340B ID
RW424881
Entity Address
One Medical Center Drive
Lebanon, NH 03756
Grant Number
H12HA31112
Participating Start Date
1/1/2018
Last Recertification Date
2/9/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
RITE AID OF VERMONT, INC.
Pharmacy Address
RITE AID #3201
621 ROUTE 22A N
FAIR HAVEN, VT 05743-9239
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
1/1/2018
Covered Entity Terminated
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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