Covered Entity Details

DSH200001 ST JOSEPH HOSPITAL (Active) - information as of 4/28/2025 1:48:29 AM

Main Details

Name

ST JOSEPH HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH200001

Medicare Provider Number

200001

Additional Details

Current Program Status

Active

Registration Date

10/14/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/30/2024

Last Recertification Date

Contacts

Authorizing Official

St. Joseph Hospital
Michael Allan Hendrix, Vice of President of Finance
(207) 907-1600

Primary Contact

St. Joseph Hospital
Courtney Mcvey, Pharmacy Operations Manager
(207) 907-1823

Addresses

Street Address

360 BROADWAY
BANGOR, ME 04401

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
ME	1154321545	1154321545

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CVS STATE CAPITAL, L.L.C.	CVS PHARMACY # 16975	60 LONGVIEW DR	BANGOR	ME	04401	04/10/2025	07/01/2025	04/10/2025
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	04/10/2025	07/01/2025	04/10/2025
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	04/10/2025	07/01/2025	04/10/2025
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	04/10/2025	07/01/2025	04/10/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	04/10/2025	07/01/2025	04/10/2025
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	04/10/2025	07/01/2025	04/10/2025
Contract Detail	GENOA HEALTHCARE LLC	42 CEDAR STREET		BANGOR	ME	04401	04/10/2025	07/01/2025	04/10/2025
Contract Detail	GENOA HEALTHCARE LLC	2 SPRINGBROOK DR STE 101		BIDDEFORD	ME	04005	04/10/2025	07/01/2025	04/10/2025
Contract Detail	GENOA HEALTHCARE LLC	841 RIVERSIDE DR STE P		AUGUSTA	ME	04330	04/10/2025	07/01/2025	04/10/2025
Contract Detail	GENOA HEALTHCARE LLC	62 ELM STREET, SUITE 23, ROOM P		PORTLAND	ME	04101	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM INFUSION SERVICES 202, INC.	9655 FLORIDA MINING BLVD W	STE 411	JACKSONVILLE	FL	32257-2041	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	7167 E. KEMPER RD.		CINCINNATI	OH	45249	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/10/2025	07/01/2025	04/10/2025
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/10/2025	07/01/2025	04/10/2025
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/10/2025	07/01/2025	04/10/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	04/10/2025	07/01/2025	04/10/2025
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-1856	900 STILLWATER AVENUE		BANGOR	ME	04401	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-1919	250 WEST BROADWAY		LINCOLN	ME	04457	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-1924	781 MAIN ST		PRESQUE ISLE	ME	04769	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-1932	17 MYRICK STREET		ELLSWORTH	ME	04605	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-1974	17 LUDLOW ROAD		HOULTON	ME	04730	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-2047	1573 MAIN STREET		PALMYRA	ME	04965	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-2178	379 SOUTH STREET		CALAIS	ME	04619	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-5076	24 WALTON DR		BREWER	ME	04412	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/15/2025	07/01/2025	04/15/2025
Contract Detail	WALGREEN EASTERN CO., INC	WALGREENS #17355	66 MOOSEHEAD TRL	NEWPORT	ME	04953	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11285	706 BROADWAY	BANGOR	ME	04401	04/07/2025	07/01/2025	04/07/2025
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11545	437 WILSON ST	BREWER	ME	04412	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #17141	566 UNION ST	BANGOR	ME	04401	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17149	220 US ROUTE 1	BUCKSPORT	ME	04416	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18000	302 MAIN ST	OLD TOWN	ME	04468	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18112	65 WESTERN AVE	HAMPDEN	ME	04444-1423	04/10/2025	07/01/2025	04/10/2025
Contract Detail	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	04/10/2025	07/01/2025	04/10/2025
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/15/2025	07/01/2025	04/15/2025
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	04/15/2025	07/01/2025	04/15/2025

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH200001A	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH ENDOCRINOLOGY - St. Joseph Endocrinology	900 BROADWAY	BANGOR	ME	Active
DSH200001B	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE 900 - St. Joseph Family Medicine - Broadway	900 BROADWAY	BANGOR	ME	Active
DSH200001C	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE HAMPDEN - St. Jospeh Family Medicine - Hampden	21 WESTERN AVE	HAMPDEN	ME	Active
DSH200001D	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH FAMILY MEDICINE MT HOPE - St. Joseph Family Medicine - Evergreen Woods	700 MOUNT HOPE AVE	BANGOR	ME	Active
DSH200001E	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH GASTROENTEROLOGY - St. Joseph Gastroenterology	360 BROADWAY	BANGOR	ME	Active
DSH200001F	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH GENERAL SURGERY AND UROLO - St. Joseph General Surgery and Urology	360 BROADWAY	BANGOR	ME	Active
DSH200001G	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH NEUROSURGERY - St. Joseph Neuroscience	360 BROADWAY	BANGOR	ME	Active
DSH200001H	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH RESPIRATORY CARE - St. Joseph Pulmonary Medicine	360 BROADWAY	BANGOR	ME	Active
DSH200001J	Child	DSH	ST JOSEPH HOSPITAL	ST JOSEPH RHEUMATOLOGY - St. Joseph Rheumatology	900 BROADWAY	BANGOR	ME	Active
DSH200001K	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Cardiology - St. Joseph Cardiovascular Care	360 Broadway	Bangor	ME	Active
DSH200001L	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Internal Medicine - St. Joseph Internal Medicine - Same Day Care	900 Broadway	Bangor	ME	Active
DSH200001M	Child	DSH	ST JOSEPH HOSPITAL	SKIN AND WOUND HEALING CENTER WITH - St. Joseph Wound Care	360 BROADWAY	BANGOR	ME	Active
DSH200001N	Child	DSH	ST JOSEPH HOSPITAL	St. Joseph Psych - St. Joseph Psych	900 Broadway	Bangor	ME	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Hendrix, Michael Allan Vice of President of Finance St. Joseph Hospital 2079071600	10/30/2024 8:29 AM
Details	340B ID	Update	New Registration		DSH200001	10/30/2024 8:29 AM
Dates	Participating Approval Date	Update	New Registration		10/30/2024 8:29:25 AM	10/30/2024 8:29 AM
Details	State	Update	New Registration	Pending	Approved	10/30/2024 8:29 AM
Dates	Signed By Date	Update	New Registration		10/29/2024 9:17:57 AM	10/30/2024 8:29 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/30/2024 8:29 AM
Addresses	Main Address	Insert	New Registration		360 BROADWAY BANGOR, ME 04401	10/14/2024 10:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	10/14/2024 10:21 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1154321545	10/14/2024 10:21 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	10/14/2024 10:21 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1154321545	10/14/2024 10:21 AM
Medicaid Billing	NPI: State	Insert	New Registration		ME	10/14/2024 10:21 AM
Contacts	Authorizing Official	Insert	New Registration		Hendrix, Michael Allan Vice of President of Finance St. Joseph Hospital 2079071600	10/14/2024 10:21 AM
Contacts	Primary Contact	Insert	New Registration		Mcvey, Courtney Pharmacy Operations Manager St. Joseph Hospital 2079071823	10/14/2024 10:21 AM
Details	Assistance Received From Date	Insert	New Registration			10/14/2024 10:21 AM
Details	Assistance Received To Date	Insert	New Registration			10/14/2024 10:21 AM
Details	Last Recertification Date	Insert	New Registration			10/14/2024 10:21 AM
Details	Grant Number	Insert	New Registration			10/14/2024 10:21 AM
Details	340B ID	Insert	New Registration			10/14/2024 10:21 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/14/2024 10:21 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/14/2024 10:21 AM
Details	Medicare Provider Number	Insert	New Registration		200001	10/14/2024 10:21 AM
Details	Entity Name	Insert	New Registration		ST JOSEPH HOSPITAL	10/14/2024 10:21 AM
Details	NOFO Number	Insert	New Registration			10/14/2024 10:21 AM
Details	Program Code	Insert	New Registration		DSH	10/14/2024 10:21 AM
Details	Entity Subname	Insert	New Registration			10/14/2024 10:21 AM
Dates	Participating Approval Date	Insert	New Registration			10/14/2024 10:21 AM
Details	State	Insert	New Registration		Pending	10/14/2024 10:21 AM
Dates	Registration Date	Insert	New Registration		10/14/2024 10:21:43 AM	10/14/2024 10:21 AM
Dates	Signed By Date	Insert	New Registration			10/14/2024 10:21 AM
Dates	Start Date	Insert	New Registration			10/14/2024 10:21 AM
Terminations	Termination Comments	Insert	New Registration			10/14/2024 10:21 AM
Terminations	Termination Date	Insert	New Registration			10/14/2024 10:21 AM
Terminations	Termination Effective Date	Insert	New Registration			10/14/2024 10:21 AM
Terminations	Termination Reason	Insert	New Registration			10/14/2024 10:21 AM