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MAXI GREEN, INC.
DSH470005 RUTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
RUTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470005
Entity Address
160 ALLEN STREET
RUTLAND, VT 05701
Medicare Provider Number
470005
Participating Start Date
7/1/2016
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10333
1 UNION STREET
BRANDON, VT 05733
Pharmacy Comments
03/01/2013 adress line 1 update (was 1 CARVER STREET)
Contract Details
Approval Date
5/2/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2018
Ownership change
Contacts
Covered Entity Signing Official
EDWARD OGORZALEK, CFO
(802) 747-1610
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
5/2/2016
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