Covered Entity Details

HM04101 MAINE MEDICAL CENTER (Active) - information as of 5/2/2025 10:31:11 PM

Main Details

Name

MAINE MEDICAL CENTER

Subdivision Name

MAINE HEMOPHILIA AND THROMBOSIS CENTER

Type

Comprehensive Hemophilia Treatment Center

340B ID

HM04101

Grant Number

H30MC24048

Additional Details

Current Program Status

Active

Registration Date

2/21/2008

Participating Start Date

4/1/2008

Participating Approval Date

2/21/2008

Last Recertification Date

2/10/2025

Contacts

Authorizing Official

MaineHealth
Chris Coon, Southern Region Vice President, Finance
(207) 662-6213

Primary Contact

MaineHealth
Louise Baca, Senior Director
(207) 396-7504

Addresses

Street Address

22 BRAMHALL ST
PORTLAND, ME 04101

Billing Address

Maine Medical Center /MAINE HEMOPHILIA AND THROMBOSIS CENTER
100 CAMPUS DRIVE
103
SCARBOROUGH, ME 04074-9308

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
History

Comments

Comment	Last Updated On
3/29/11 ADDED NPI	02/21/2008

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Shipping Address 1

Maine Medical Center/Maine Hemophilia and Thrombosis Center
100 Campus Drive
103
Scarborough, ME 04074

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	CURA PHARMACY	17400 IRVINE BLVD STE P		TUSTIN	CA	92780-3030	10/08/2013	01/01/2014	12/02/2015	12/02/2015
Contract Detail	EVERSANA LIFE SCIENCE SERVICES, LLC	17877 CHESTERFIELD AIRPORT ROAD		CHESTERFIELD	MO	63005-1211	07/07/2014	10/01/2014	01/30/2017	01/30/2017
Contract Detail	MAINEHEALTH	MAINEHEALTH PHARMACY MAINE MEDICAL CENTE	22 BRAMHALL ST	PORTLAND	ME	04102	01/29/2022	04/01/2022		04/01/2022
Contract Detail	NEW ENGLAND LIFE CARE	45 CENTER STREET SUITE A		SCARBOROUGH	ME	04074	10/08/2013	01/01/2014		10/08/2013
Contract Detail	OPTUM INFUSION SERVICES 101, INC.	931 CONKLIN ST STE D		FARMINGDALE	NY	11735-2429	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM INFUSION SERVICES 201, INC.	5700 DOT COM CT STE 1030		OVIEDO	FL	32765-3400	04/26/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	04/26/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	4000 CHEMICAL RD STE 100		PLYMOUTH MEETING	PA	19462	04/26/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	4900 RIVERGRADE RD STE E120		IRWINDALE	CA	91706-1419	04/26/2022	07/01/2022	04/05/2023	04/06/2023
Contract Detail	OPTUM INFUSION SERVICES 500, INC.	33 N PLAINS INDUSTRIAL RD STE B		WALLINGFORD	CT	06492-5841	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	7167 E. KEMPER RD.		CINCINNATI	OH	45249	04/26/2022	07/01/2022		07/01/2022
Contract Detail	OPTUM INFUSION SERVICES 550, LLC	20 COMMERCE WAY	SUITE 2	WOBURN	MA	01801	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM INFUSION SERVICES 551, LLC	100 CORPORATE DR STE 111		WINDSOR	CT	06095	04/26/2022	07/01/2022	04/05/2023	04/06/2023
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/06/2023	07/01/2023		07/01/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	04/06/2023	07/01/2023		07/01/2023
Contract Detail	POSITUDES INC	44 BOND ST		WESTBURY	NY	11590	04/26/2022	07/01/2022		07/01/2022
Contract Detail	RED CHIP OF NEVADA	18009 SKY PARK CIRCLE SUITE F		IRVINE	CA	92614-9261	01/05/2015	04/01/2015		06/29/2021
Contract Detail	Red Chip of Nevada	18009 Sky Park Circle, Suite G		Irvine	CA	92614	10/06/2015	10/06/2015	02/05/2024	02/06/2024
Contract Detail	STONE SOUP ENTERPRISES, INC.	18009 SKYPARK CIRCLE, STE G		IRVINE	CA	92614	11/15/2009	11/15/2009	12/02/2015	12/02/2015

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/6/2024 11:09:52 AM	2/10/2025 6:31:29 AM	2/10/2025 6:31 AM
Contacts	Primary Contact	Update	Change Request	Roy, Glen RN Nurse Coordinator Maine Medical Center/Maine Hemophilia and Thrombosis Center 2073967683	Baca, Louise Senior Director MaineHealth 2073967504	2/9/2025 12:22 PM
Contacts	Authorizing Official	Update	Change Request	Inzana, Lugene Anthony CFO Maine Medical Center 2076622654	Coon, Chris Southern Region Vice President, Finance MaineHealth 2076626213	2/6/2025 7:37 AM
Addresses	Billing Address	Update	Recertification	Maine Medical Center /MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, Suite 103 SCARBOROUGH, ME 04074-9308	Maine Medical Center /MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE 103 SCARBOROUGH, ME 04074-9308	2/6/2024 11:09 AM
Contacts	Primary Contact	Update	Recertification	ROY, GLEN NURSE COORDINATOR MMC/Maine Hemophilia and Thrombosis Center 2073967683	Roy, Glen RN Nurse Coordinator Maine Medical Center/Maine Hemophilia and Thrombosis Center 2073967683	2/6/2024 11:09 AM
Details	Last Recertification Date	Update	Recertification	2/27/2023 11:16:19 AM	2/6/2024 11:09:52 AM	2/6/2024 11:09 AM
Addresses	Billing Address	Update	Recertification	MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, Suite 103 SCARBOROUGH, ME 04074-9308	Maine Medical Center /MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, Suite 103 SCARBOROUGH, ME 04074-9308	2/27/2023 11:16 AM
Addresses	Shipping Address	Insert	Recertification		Maine Medical Center/Maine Hemophilia and Thrombosis Center 100 Campus Drive 103 Scarborough, ME 04074	2/27/2023 11:16 AM
Details	Last Recertification Date	Update	Recertification	2/23/2022 12:09:47 PM	2/27/2023 11:16:19 AM	2/27/2023 11:16 AM
Details	Last Recertification Date	Update	Recertification	2/16/2021 3:42:49 PM	2/23/2022 12:09:47 PM	2/23/2022 12:09 PM
Details	Last Recertification Date	Update	Recertification	2/7/2020 2:18:30 PM	2/16/2021 3:42:49 PM	2/16/2021 3:42 PM
Addresses	Billing Address	Update	Change Request	MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, UNIT 107 SCARBOROUGH, ME 04074-9308	MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, Suite 103 SCARBOROUGH, ME 04074-9308	1/21/2021 9:48 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1053647024 ( )		1/18/2021 9:57 AM
Details	Last Recertification Date	Update	Recertification	2/4/2019 12:14:38 PM	2/7/2020 2:18:30 PM	2/7/2020 2:18 PM
Details	Last Recertification Date	Update	Recertification	2/16/2018 9:47:46 AM	2/4/2019 12:14:38 PM	2/4/2019 12:14 PM
Details	Last Recertification Date	Update	Recertification	2/16/2017 12:00:00 AM	2/16/2018 9:47:46 AM	2/16/2018 9:47 AM
Contacts	Authorizing Official	Update		Inzana, Lugene CFO 2076622654	Inzana, Lugene Anthony CFO Maine Medical Center 2076622654	10/16/2017 11:02 AM
Contacts	Primary Contact	Update		ROY, GLEN NURSE COORDINATOR 2073967683	ROY, GLEN NURSE COORDINATOR MMC/Maine Hemophilia and Thrombosis Center 2073967683	10/4/2017 1:32 PM
Contacts	Authorizing Official	Insert			Inzana, Lugene CFO 2076622654	7/17/2017 8:52 AM
Addresses	Main Address	Insert			22 BRAMHALL ST PORTLAND, ME 04101	2/16/2017 8:43 AM
Contacts	Primary Contact	Insert			ROY, GLEN NURSE COORDINATOR 2073967683	2/16/2017 8:43 AM
Details	Last Recertification Date	Update		2/24/2016 12:00:00 AM	2/16/2017 12:00:00 AM	2/16/2017 8:43 AM
Details	Last Recertification Date	Update		1/29/2015 12:00:00 AM	2/24/2016 12:00:00 AM	2/24/2016 12:09 PM
Addresses	Billing Address	Insert			MAINE HEMOPHILIA AND THROMBOSIS CENTER 100 CAMPUS DRIVE, UNIT 107 SCARBOROUGH, ME 04074-9308	10/15/2015 5:48 PM
Details	Last Recertification Date	Update		2/14/2014 12:00:00 AM	1/29/2015 12:00:00 AM	1/29/2015 12:26 PM
Details	Last Recertification Date	Update		4/1/2013 12:00:00 AM	2/14/2014 12:00:00 AM	2/14/2014 3:17 PM
Details	Last Recertification Date	Update			4/1/2013 12:00:00 AM	2/7/2013 12:36 PM
Details	Grant Number	Update		H30MC00037	H30MC24048	1/16/2013 1:18 PM
Details	Grant Number	Update			H30MC00037	12/27/2012 12:37 PM
Details	Grant Number	Update		H30MC00037		3/29/2011 3:58 PM
Medicaid Billing	NPI: Number	Insert			1053647024	2/21/2008 9:34 AM
Details	Last Recertification Date	Insert				2/21/2008 9:34 AM
Details	Grant Number	Insert			H30MC00037	2/21/2008 9:34 AM
Details	340B ID	Insert			HM04101	2/21/2008 9:34 AM
Details	Is Authorizing Official EHB Data	Insert				2/21/2008 9:34 AM
Dates	Last Date That 340B Drugs Purchased	Insert				2/21/2008 9:34 AM
Details	Medicare Provider Number	Insert				2/21/2008 9:34 AM
Details	Entity Name	Insert			MAINE MEDICAL CENTER	2/21/2008 9:34 AM
Details	Program Code	Insert			HM	2/21/2008 9:34 AM
Details	Entity Subname	Insert			MAINE HEMOPHILIA AND THROMBOSIS CENTER	2/21/2008 9:34 AM
Dates	Participating Approval Date	Insert			2/21/2008 12:00:00 AM	2/21/2008 9:34 AM
Details	State	Insert			Active	2/21/2008 9:34 AM
Dates	Registration Date	Insert			2/21/2008 12:00:00 AM	2/21/2008 9:34 AM
Dates	Signed By Date	Insert			11/27/2007 12:00:00 AM	2/21/2008 9:34 AM
Dates	Start Date	Insert			4/1/2008 12:00:00 AM	2/21/2008 9:34 AM
Terminations	Termination Comments	Insert				2/21/2008 9:34 AM
Terminations	Termination Date	Insert				2/21/2008 9:34 AM
Terminations	Termination Effective Date	Insert				2/21/2008 9:34 AM
Terminations	Termination Reason	Insert				2/21/2008 9:34 AM
Details	Comments Public	Insert			3/29/11 ADDED NPI	2/21/2008 9:34 AM

340B Drug Pricing Program Database

Comments

Medicaid Billing

Shipping Addresses

Contract Pharmacies

History