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MAXI GREEN, INC.
HV00812B 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
Bedford Clinic, Ryan White Part C
Type
Ryan White Part C
340B ID
HV00812B
Entity Address
5 Washington Place
Bedford, NH 03110
Grant Number
H76HA31654
Participating Start Date
7/1/2016
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
MAXI GREEN, INC.
Pharmacy Address
RITE AID #10317
158 CHERRY STREET
BURLINGTON, VT 05401
Pharmacy Comments
Contract Details
Approval Date
4/19/2016
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
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
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