Covered Entity Details

CAH201301-00 CHARLES A. DEAN MEMORIAL HOSPITAL (Active) - information as of 4/28/2025 12:42:12 AM

Main Details

Name

CHARLES A. DEAN MEMORIAL HOSPITAL

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH201301-00

Medicare Provider Number

201301

Additional Details

Current Program Status

Active

Registration Date

11/23/2010

Participating Start Date

1/1/2011

Participating Approval Date

12/7/2010

Last Recertification Date

9/9/2024

Contacts

Authorizing Official

CA Dean
JENNIFER GOODRICH, CFO
(207) 695-5209

Primary Contact

Northern Light CA Dean and Mayo Hospitals
Deidre Gilbert, Regional Director of Pharmacy
(207) 695-5270

Addresses

Street Address

364 PRITHAM AVENUE
GREENVILLE, ME 04441

Billing Address

CHARLES A. DEAN MEMORIAL HOSPITAL
43 WHITING HILL RD
BREWER, ME 04412

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
3/6/12- Updated entity name (was CHARLES A. DEAN MEMORIAL HOSPITAL AND NURSING HOME)	03/06/2012

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	153970200,153970000	1265441323,1659388213

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	M DRUG LLC	DBA NORTHERN LIGHT PHARMACY	70 BENNETT ST	BANGOR	ME	04401	01/26/2015	04/01/2015	06/06/2017	07/20/2017
Contract Detail	M DRUG LLC	DBA NORTHERN LIGHT PHARMACY	70 BENNETT ST	BANGOR	ME	04401	07/15/2020	10/01/2020		10/01/2020
Contract Detail	MOOSEHEAD DRUG INC	HARRIS DRUG STORE	PO BOX 530 10 PRITHAM AVENUE	GREENVILLE	ME	04441-0530	04/14/2014	07/01/2014		07/20/2017
Contract Detail	RITE AID OF MAINE, INC.	RITE AID #2785	3 HUDSON AVENUE PO BOX 147	GUILFORD	ME	04443	04/15/2013	07/01/2013	01/25/2018	04/23/2018
Contract Detail	RITE AID OF MAINE, INC.	RITE AID #3897	35 PARK STREET	MILO	ME	04463	04/15/2013	07/01/2013	06/06/2017	07/20/2017
Contract Detail	RITE AID OF MAINE, INC.	RITE AID #2080	151 EAST MAIN STREET	DOVER-FOXCROFT	ME	04426	04/18/2016	07/01/2016	01/25/2018	04/23/2018
Contract Detail	SHAWS SUPERMARKETS INC	SHAWS PHARMACY #0629	1073 W. MAIN ST	DOVER FOXCROFT	ME	04426	10/17/2017	01/01/2018		10/17/2017
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #17989	151 E MAIN ST	DOVER FOXCROFT	ME	04426	02/07/2018	02/07/2018		02/07/2018
Contract Detail	WALGREEN EASTERN CO., INC.	WALGREENS #18411	3 HUDSON AVE	GUILFORD	ME	04443	02/07/2018	02/07/2018	09/18/2023	10/23/2023
Contract Detail	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	07/17/2023	10/01/2023		10/01/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH201301-01	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	NORTHWOODS HEALTHCARE SANGERVILLE	22 HALEY CT	SANGERVILLE	ME	Active
CAH201301-02	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	NORTHWOODS HEALTHCARE	364 PRITHAM AVE	GREENVILLE	ME	Active
CAH201301-03	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	NORTHWOODS HEALTHCARE MONSON	7 GREENVILLE RD	MONSON	ME	Active
CAH201301-04	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	NORTHWOODS HEALTHCARE SPECIALTY CLINIC	364 PRITHAM AVENUE	GREENVILLE	ME	Active
CAH201301-05	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	Geriatric Services	364 Pritham Ave.	Greenville	ME	Terminated
CAH201301-06	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	CHARLES A. DEAN MEMORIAL HOSPITAL / Wound Care	364 PRITHAM AVE	GREENVILLE	ME	Terminated
CAH201301-07	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	Northern Light Integrated Behavioral Health - Greenville - Behavioral Health	364 Pritham Ave	Greenville	ME	Approved
CAH201301-08	Child	CAH	CHARLES A. DEAN MEMORIAL HOSPITAL	NORTHERN LIGHT INTEGRATED BEHAVIORAL HEALTH - SANGERVILLE - BEHAVIORAL HEALTH	22 HALEY COURT	SANGERVILLE	ME	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Change Request	Gilbert, Deidre Regional Director of Pharmacy Northern Light CA Dean and Mayo Hospitals 2076959160	Gilbert, Deidre Regional Director of Pharmacy Northern Light CA Dean and Mayo Hospitals 2076955270	3/25/2025 10:11 AM
Contacts	Primary Contact	Update	Profile Change Request	Gilbert, Deidre Regional Director of Pharmacy Northern Light CA Dean and Mayo Hospitals 2076955270	Gilbert, Deidre Regional Director of Pharmacy Northern Light CA Dean and Mayo Hospitals 2076959160	3/25/2025 10:05 AM
Details	Last Recertification Date	Update	Recertification	9/6/2023 4:16:38 PM	9/9/2024 11:44:28 AM	9/9/2024 11:44 AM
Details	Last Recertification Date	Update	Recertification	9/1/2022 12:00:53 PM	9/6/2023 4:16:38 PM	9/6/2023 4:16 PM
Contacts	Primary Contact	Update	Profile Change Request	Gilbert, Deidre Director of Pharmacy Charles A Dean Memorial Hospital 2076955270	Gilbert, Deidre Regional Director of Pharmacy Northern Light CA Dean and Mayo Hospitals 2076955270	3/22/2023 6:16 AM
Details	Last Recertification Date	Update	Recertification	9/9/2021 8:57:18 PM	9/1/2022 12:00:53 PM	9/1/2022 12:00 PM
Details	Last Recertification Date	Update	Recertification	8/31/2020 8:22:05 AM	9/9/2021 8:57:18 PM	9/9/2021 8:57 PM
Medicaid Billing	NPI: State	Update	Recertification		ME	8/31/2020 8:22 AM
Medicaid Billing	NPI: State	Update	Recertification		ME	8/31/2020 8:22 AM
Details	Last Recertification Date	Update	Recertification	9/10/2019 1:31:24 PM	8/31/2020 8:22:05 AM	8/31/2020 8:22 AM
Details	Last Recertification Date	Update	Recertification	8/22/2018 9:48:22 AM	9/10/2019 1:31:24 PM	9/10/2019 1:31 PM
Details	Last Recertification Date	Update	Recertification	11/7/2017 12:25:31 PM	8/22/2018 9:48:22 AM	8/22/2018 9:48 AM
Details	Last Recertification Date	Update	Recertification	10/25/2017 8:21:46 AM	11/7/2017 12:25:31 PM	11/7/2017 12:25 PM
Details	Last Recertification Date	Update	Recertification	8/11/2016 12:00:00 AM	10/25/2017 8:21:46 AM	10/25/2017 8:21 AM
Contacts	Authorizing Official	Update		GOODRICH, JENNIFER CFO 2076955209	GOODRICH, JENNIFER CFO CA Dean 2076955209	10/17/2017 9:32 AM
Contacts	Primary Contact	Update		Gilbert, Deidre Director of Pharmacy 2076955270	Gilbert, Deidre Director of Pharmacy Charles A Dean Memorial Hospital 2076955270	10/12/2017 8:32 AM
Addresses	Main Address	Insert			364 PRITHAM AVENUE GREENVILLE, ME 04441	7/20/2017 12:50 PM
Addresses	Billing Address	Insert			CHARLES A. DEAN MEMORIAL HOSPITAL 43 WHITING HILL RD BREWER, ME 04412	7/20/2017 12:50 PM
Contacts	Authorizing Official	Update		MURRAY, EUGENE F. CEO 2076955271	GOODRICH, JENNIFER CFO 2076955209	7/20/2017 12:50 PM
Contacts	Primary Contact	Update		PRATT, DEIDRE DIRECTOR OF PHARMACY 2076955270	Gilbert, Deidre Director of Pharmacy 2076955270	7/20/2017 12:50 PM
Contacts	Authorizing Official	Insert			MURRAY, EUGENE F. CEO 2076955271	8/11/2016 1:38 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/11/2016 12:00:00 AM	8/11/2016 1:38 PM
Contacts	Primary Contact	Update		SCHACK, MELISSA DIRECTOR OF PHARMACY 2076955270	PRATT, DEIDRE DIRECTOR OF PHARMACY 2076955270	8/17/2015 4:27 PM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/5/2015 9:13 AM
Details	Last Recertification Date	Update		9/3/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 9:13 AM
Contacts	Primary Contact	Insert			SCHACK, MELISSA DIRECTOR OF PHARMACY 2076955270	9/8/2014 7:46 AM
Details	Last Recertification Date	Update		8/19/2013 12:00:00 AM	9/3/2014 12:00:00 AM	9/3/2014 1:31 PM
Details	Last Recertification Date	Update		8/19/2013 2:42:42 PM	8/19/2013 12:00:00 AM	4/30/2014 1:36 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	8/19/2013 2:42:42 PM	8/19/2013 2:42 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/1/2012 7:45 AM
Details	Entity Name	Update		CHARLES A. DEAN MEMORIAL HOSPITAL AND NURSING HOME	CHARLES A. DEAN MEMORIAL HOSPITAL	3/6/2012 9:57 AM
Details	Comments Public	Insert			3/6/12- Updated entity name (was CHARLES A. DEAN MEMORIAL HOSPITAL AND NURSING HOME)	3/6/2012 9:57 AM
Details	Last Recertification Date	Insert				12/7/2010 2:03 PM
Details	Grant Number	Insert				12/7/2010 2:03 PM
Details	340B ID	Insert			CAH201301-00	12/7/2010 2:03 PM
Details	Is Authorizing Official EHB Data	Insert				12/7/2010 2:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				12/7/2010 2:03 PM
Details	Medicare Provider Number	Insert			201301	12/7/2010 2:03 PM
Details	Entity Name	Insert			CHARLES A. DEAN MEMORIAL HOSPITAL AND NURSING HOME	12/7/2010 2:03 PM
Details	Program Code	Insert			CAH	12/7/2010 2:03 PM
Details	Entity Subname	Insert				12/7/2010 2:03 PM
Dates	Participating Approval Date	Insert			12/7/2010 12:00:00 AM	12/7/2010 2:03 PM
Details	State	Insert			Active	12/7/2010 2:03 PM
Dates	Registration Date	Insert			11/23/2010 12:00:00 AM	12/7/2010 2:03 PM
Dates	Signed By Date	Insert			11/29/2010 12:00:00 AM	12/7/2010 2:03 PM
Dates	Start Date	Insert			1/1/2011 12:00:00 AM	12/7/2010 2:03 PM
Terminations	Termination Comments	Insert				12/7/2010 2:03 PM
Terminations	Termination Date	Insert				12/7/2010 2:03 PM
Terminations	Termination Effective Date	Insert				12/7/2010 2:03 PM
Terminations	Termination Reason	Insert				12/7/2010 2:03 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	11/23/2010 12:21 PM
Medicaid Billing	Medicaid: Number	Insert			153970200	11/23/2010 12:21 PM
Medicaid Billing	Medicaid: State	Insert			ME	11/23/2010 12:21 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	11/23/2010 12:21 PM
Medicaid Billing	Medicaid: Number	Insert			153970000	11/23/2010 12:21 PM
Medicaid Billing	Medicaid: State	Insert			ME	11/23/2010 12:21 PM
Medicaid Billing	NPI: Number	Insert			1265441323	11/23/2010 12:21 PM
Medicaid Billing	NPI: Number	Insert			1659388213	11/23/2010 12:21 PM