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RITE AID OF VERMONT, INC.
HV00812A 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
Dartmouth-Hitchcock Manchester, Ryan White Part C
Type
Ryan White Part C
340B ID
HV00812A
Entity Address
100 Hitchcock Way
Manchester, NH 03104
Grant Number
H76HA31654
Participating Start Date
7/1/2016
Last Recertification Date
2/28/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
RITE AID OF VERMONT, INC.
Pharmacy Address
RITE AID #1174
P.O. BOX 90
294 MAIN STREET
WEST RUTLAND, VT 05777
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
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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