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WALGREEN EASTERN CO., INC.
RW424881A 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 D
Type
Ryan White Part D
340B ID
RW424881A
Entity Address
100 Hitchcock Way
Manchester, NH 03104
Grant Number
H12HA31112
Participating Start Date
7/1/2016
Last Recertification Date
2/9/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
DBA: WALGREENS #11376
142 LOUDON RD.
CONCORD, NH 03301-5637
Pharmacy Comments
Contract Details
Approval Date
1/16/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas J. Siepka, CHIEF PHARMACY OFFICER
(603) 650-5738
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/16/2018
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