Covered Entity Details

DSH200050Q MAINE COAST MEMORIAL HOSPITAL (Approved) - information as of 5/13/2025 10:54:04 PM

Main Details

Name

MAINE COAST MEMORIAL HOSPITAL

Subdivision Name

Northern Light Diabetes Clinic Ellsworth - Diabetes

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH200050Q

Medicare Provider Number

200050

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/15/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/24/2025

Last Recertification Date

Contacts

Authorizing Official

Maine Coast Hospital
Wendy June Merchant, VP of Finance
(207) 610-2429

Primary Contact

Northern Light Health
Corey Michael Taylor, Director of Pharmacy
(207) 664-5468

Addresses

Street Address

32 RESORT WAY
ELLSWORTH, ME 04605

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	101630000	1740249739

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH200050A	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY/ELEANOR WIDENER DIXON MEMORIAL CLINIC/Family Practice	37 CLINIC RD	GOULDSBORO	ME	Terminated
DSH200050B	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET	ELLSWORTH	ME	Terminated
DSH200050C	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY / Family Practice	306 MAIN ST	ELLSWORTH	ME	Terminated
DSH200050D	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET STE 3200	ELLSWORTH	ME	Terminated
DSH200050E	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	MAINE COAST PEDIATRICS	ELLSWORTH	ME	Terminated
DSH200050F	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET STE 1100	ELLSWORTH	ME	Terminated
DSH200050G	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET STE 2200	ELLSWORTH	ME	Terminated
DSH200050H	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	ELLSWORTH FAMILY PRACTICE	ELLSWORTH	ME	Terminated
DSH200050J	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION ST STE 2100	ELLSWORTH	ME	Terminated
DSH200050K	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET STE 1400	ELLSWORTH	ME	Terminated
DSH200050L	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY	50 UNION STREET STE 2300	ELLSWORTH	ME	Terminated
DSH200050M	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY / Family Practice	45 HERRICK RD	SOUTHWEST HARBOR	ME	Terminated
DSH200050N	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	MAINE COAST REGIONAL HEALTH FACILITY / Internal Medicine	ELLSWORTH INTERNAL MEDICINE	ELLSWORTH	ME	Terminated
DSH200050P	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	NICHOLAS S. VACHON, DPM - Podiatry	318 MAIN ST	ELLSWORTH	ME	Approved
DSH200050Q	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	Northern Light Diabetes Clinic Ellsworth - Diabetes	32 RESORT WAY	ELLSWORTH	ME	Approved
DSH200050R	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	Northern Light Wound Care Ellsworth - Wound	32 RESORT WAY	ELLSWORTH	ME	Approved
DSH200050S	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	ELLSWORTH FAMILY PRACTICE - Primary Care	32 RESORT WAY	ELLSWORTH	ME	Approved
DSH200050T	Child	DSH	MAINE COAST MEMORIAL HOSPITAL	ELEANOR WIDENER DIXON MEMORIAL CLIN - Primary Care	37 CLINIC RD	GOULDSBORO	ME	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Merchant, Wendy June VP of Finance Maine Coast Hospital 2076102429	4/24/2025 2:16 PM
Details	340B ID	Update	New Registration		DSH200050Q	4/24/2025 2:16 PM
Details	Entity Subname	Update	New Registration	Northern Light Diabetes Clinic Ellsworth	Northern Light Diabetes Clinic Ellsworth - Diabetes	4/24/2025 2:16 PM
Dates	Participating Approval Date	Update	New Registration		4/24/2025 2:16:51 PM	4/24/2025 2:16 PM
Details	State	Update	New Registration	Pending	Approved	4/24/2025 2:16 PM
Dates	Signed By Date	Update	New Registration		4/15/2025 12:02:48 PM	4/24/2025 2:16 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/24/2025 2:16 PM
Addresses	Main Address	Insert	New Registration		32 RESORT WAY ELLSWORTH, ME 04605	4/15/2025 7:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/15/2025 7:58 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		101630000	4/15/2025 7:58 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/15/2025 7:58 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1740249739	4/15/2025 7:58 AM
Medicaid Billing	NPI: State	Insert	New Registration		ME	4/15/2025 7:58 AM
Contacts	Authorizing Official	Insert	New Registration		Merchant, Wendy June VP of Finance Maine Coast Hospital 2076102429	4/15/2025 7:58 AM
Contacts	Primary Contact	Insert	New Registration		Taylor, Corey Michael Director of Pharmacy Northern Light Health 2076645468	4/15/2025 7:58 AM
Details	Assistance Received From Date	Insert	New Registration			4/15/2025 7:58 AM
Details	Assistance Received To Date	Insert	New Registration			4/15/2025 7:58 AM
Details	Last Recertification Date	Insert	New Registration			4/15/2025 7:58 AM
Details	Grant Number	Insert	New Registration			4/15/2025 7:58 AM
Details	340B ID	Insert	New Registration			4/15/2025 7:58 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/15/2025 7:58 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/15/2025 7:58 AM
Details	Medicare Provider Number	Insert	New Registration		200050	4/15/2025 7:58 AM
Details	Entity Name	Insert	New Registration		MAINE COAST MEMORIAL HOSPITAL	4/15/2025 7:58 AM
Details	NOFO Number	Insert	New Registration			4/15/2025 7:58 AM
Details	Program Code	Insert	New Registration		DSH	4/15/2025 7:58 AM
Details	Entity Subname	Insert	New Registration		Northern Light Diabetes Clinic Ellsworth	4/15/2025 7:58 AM
Dates	Participating Approval Date	Insert	New Registration			4/15/2025 7:58 AM
Details	State	Insert	New Registration		Pending	4/15/2025 7:58 AM
Dates	Registration Date	Insert	New Registration		4/15/2025 7:58:51 AM	4/15/2025 7:58 AM
Dates	Signed By Date	Insert	New Registration			4/15/2025 7:58 AM
Dates	Start Date	Insert	New Registration			4/15/2025 7:58 AM
Terminations	Termination Comments	Insert	New Registration			4/15/2025 7:58 AM
Terminations	Termination Date	Insert	New Registration			4/15/2025 7:58 AM
Terminations	Termination Effective Date	Insert	New Registration			4/15/2025 7:58 AM
Terminations	Termination Reason	Insert	New Registration			4/15/2025 7:58 AM