Contract Pharmacy Details

WALGREEN EASTERN CO., INC.
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

MARY HITCHCOCK MEMORIAL HOSPITAL

Subdivision Name

Type

Rural Referral Center

340B ID

RRC300003-00

Entity Address

ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001

Medicare Provider Number

300003

Participating Start Date

9/28/2010

Last Recertification Date

9/15/2021

Entity Termination Date

7/1/2022

Pharmacy Details

Pharmacy Name

WALGREEN EASTERN CO., INC.

Pharmacy Address

RITE AID #10332
7 WEST ST
RUTLAND, VT 05701

Pharmacy Comments

Contract Details

Approval Date

2/9/2018

Contract Begin Date

2/13/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/4/2022
Pharmacy closed

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

2/9/2018

340B Drug Pricing Program Database