Covered Entity Details

DSH200063S PENOBSCOT BAY MEDICAL CENTER (Active) - information as of 5/17/2025 10:59:53 PM

Main Details

Name

PENOBSCOT BAY MEDICAL CENTER

Subdivision Name

Pen Bay ENT

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH200063S

Medicare Provider Number

200063

Outpatient Facility Provider Number

200063

Additional Details

Current Program Status

Active

Registration Date

7/5/2013

Participating Start Date

10/1/2013

Participating Approval Date

9/11/2013

Last Recertification Date

8/24/2024

Contacts

Authorizing Official

Coastal Healthcare Alliance
Heather Shanklin, Chief Financial Officer
(207) 505-4131

Primary Contact

Coastal Health Alliance, MaineHealth
David MacMillan, Pharmacy Director
(207) 301-8563

Addresses

Street Address

15 Anchor Drive, Suite 102
Rockport, ME 04856

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	01-0238552	1578043378,1982645305

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
DSH200063A	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Waldoboro Family Medicine	27 Mill Street	Waldoboro	ME	Active
DSH200063AA	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PEN BAY PODIATRY	4 Glen Cove Drive, Suite 205	Rockport	ME	Active
DSH200063AB	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Surgical Skin Center	731 Commercial Street	Rockport	ME	Terminated
DSH200063AC	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Skin Center	8 Wellness Avenue	Rockport	ME	Active
DSH200063AD	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Gastroenterology	4 Glen Cove Dr.	Rockport	ME	Active
DSH200063AE	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Wound Healing Center	4 Glen Cove Drive, Suite 103	Rockport	ME	Active
DSH200063AF	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBMC ANTICOAG CLINIC - Anticoagulation Clinic	4 Glen Cove Dr	Rockport	ME	Active
DSH200063AG	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA Nephrology - Nephrology	15 Anchor Drive	Rockport	ME	Active
DSH200063AH	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBMC DIABETES & NUTRITION CARE CENTER - Diabetes and Nutrition	4 Glen Cove Dr	Rockport	ME	Active
DSH200063AJ	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA PALLIATIVE CARE - Palliative Care	4 Glen Cove Dr	Rockport	ME	Active
DSH200063AK	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA RESPIRATORY HEALTH CENTER - Respiratory	731 Commercial Street	Rockport	ME	Terminated
DSH200063AL	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA PULMONOLOGY - Pulmonology	4 Glen Cove Dr	Rockport	ME	Active
DSH200063AM	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA PRIMARY CARE ROCKLAND - PRIMARY CARE	75 Maverick St	Rockland	ME	Active
DSH200063AN	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA WALK IN CLINIC - WALK IN CARE	75 Maverick St	Rockland	ME	Active
DSH200063AP	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA PAIN MANAGEMENT AND PHYSICAL MEDICINE - Physical Medicine & Interventional Pain Management	4 Glen Cove Dr	Rockport	ME	Terminated
DSH200063AQ	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PBPA Dermatology - Dermatology	8 Wellness Ave	Rockport	ME	Active
DSH200063AR	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	MaineHealth Cardiology-Rockport - Cardiology	4 Glen Cove Dr	Rockport	ME	Approved
DSH200063C	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Surgery	4 Glen Cove Drive, Suite 103	Rockport	ME	Active
DSH200063F	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Internal Medicine	15 Anchor Drive, Suite 202	Rockport	ME	Active
DSH200063G	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Neurology	4 Glen Cove Drive, Suite 201	Rockport	ME	Active
DSH200063H	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Urology	3 Glen Cove Drive, Suite 3	Rockport	ME	Active
DSH200063J	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Women's Health	3 Glen Cove Drive, Suite 1	Rockport	ME	Active
DSH200063K	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Pediatrics	15 Anchor Drive, Suite 103	Rockport	ME	Active
DSH200063L	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Speech and Hearing/Pediatric PT and OT	15 Anchor Drive, Suite 104	Rockport	ME	Terminated
DSH200063M	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Specialty Clinic	79 Schooner Street, Suite 1	Damariscotta	ME	Terminated
DSH200063N	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Center for Sleep Medicine	7 Madelyn Lane Suite 100	Rockport	ME	Terminated
DSH200063P	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Dr. Robert Merrill MD Family Medicine	821 Commercial Street, Unit 3	Rockport	ME	Terminated
DSH200063Q	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Dr. Robert Laurence MD Internal Medicine	760 Commercial Street	Rockport	ME	Active
DSH200063R	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Dr. Parker Chamberlain MD ENT	4 Glen Cove Drive, Suite 207	Rockport	ME	Terminated
DSH200063S	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay ENT	15 Anchor Drive, Suite 102	Rockport	ME	Active
DSH200063T	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Physical Therapy - Waldoboro	40 Washington Street	Waldoboro	ME	Terminated
DSH200063U	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	PT YMCA Clinic	116 Union Street	Rockport	ME	Terminated
DSH200063V	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Outpatient PT OT PBMC	4 Glen Cove Drive, Suite 109	Rockport	ME	Terminated
DSH200063W	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Orthopedics	4 Glen Cove Drive, Suite 206	Rockport	ME	Active
DSH200063X	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Family Medicine	15 Anchor Drive, Suite 201	Rockport	ME	Active
DSH200063Y	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Medicine and Infectious Diseases	4 Glen Cove Drive, Suite 102	Rockport	ME	Active
DSH200063Z	Child	DSH	PENOBSCOT BAY MEDICAL CENTER	Pen Bay Rheumatology	4 Glen Cove, STE 202	ROCKPORT	ME	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/29/2023 8:30:59 AM	8/24/2024 10:15:27 AM	8/24/2024 10:15 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1982645305	10/19/2023 8:29 AM
Medicaid Billing	NPI: State	Insert	Change Request		ME	10/19/2023 8:29 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 8:20:25 AM	8/29/2023 8:30:59 AM	8/29/2023 8:30 AM
Contacts	Primary Contact	Update	Group Change Request	Hoang, Minh Director of 340B and Drug Supply Management Maine Health 2076628064	MacMillan, David Pharmacy Director Coastal Health Alliance, MaineHealth 2073018563	11/28/2022 4:01 PM
Details	Last Recertification Date	Update	Recertification	8/19/2021 12:09:09 PM	8/29/2022 8:20:25 AM	8/29/2022 8:20 AM
Contacts	Authorizing Official	Update	Change Request	Drinkwater, Linda CFO Waldo County General Hospital 2075054104	Shanklin, Heather Chief Financial Officer Coastal Healthcare Alliance 2075054131	1/24/2022 1:29 PM
Contacts	Primary Contact	Update	Group Change Request	MacMillan, David Director of Pharmacy Waldo County General Hospital 2073018563	Hoang, Minh Director of 340B and Drug Supply Management Maine Health 2076628064	9/3/2021 1:45 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 3:41:17 PM	8/19/2021 12:09:09 PM	8/19/2021 12:09 PM
Addresses	Main Address	Update	Change Request	68 Ben Paul Lane Rockport, ME 04856	15 Anchor Drive, Suite 102 Rockport, ME 04856	1/5/2021 6:58 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1578043378 ( )		8/26/2020 3:41 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1578043378	8/26/2020 3:41 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/26/2020 3:41 PM
Details	Last Recertification Date	Update	Recertification	8/25/2019 11:51:29 AM	8/26/2020 3:41:17 PM	8/26/2020 3:41 PM
Contacts	Primary Contact	Update	Change Request	Needham, Denise Regional Director of Pharmacy Waldo County General Hospital and Pen Bay Medical Center 2079218577	MacMillan, David Director of Pharmacy Waldo County General Hospital 2073018563	4/13/2020 5:20 PM
Details	Entity Subname	Update	Change Request	Pen Bay Otolaryngology - Dr. Charles Kava, Clinic	Pen Bay ENT	11/7/2019 9:36 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 9:51:41 AM	8/25/2019 11:51:29 AM	8/25/2019 11:51 AM
Medicaid Billing	Medicaid: Number	Update	Change Request	1982645305	01-0238552	1/15/2019 4:19 PM
Medicaid Billing	NPI: Number	Update	Change Request	1982645305	1578043378	1/15/2019 4:19 PM
Details	Entity Subname	Update	Change Request	Penobscot Bay Otolaryngology - Dr. Charles Kava, Clinic	Pen Bay Otolaryngology - Dr. Charles Kava, Clinic	1/15/2019 4:19 PM
Contacts	Authorizing Official	Update	Profile Change Request	Drinkwater, Linda CFO Waldo County General Hospital 2073389304-4104	Drinkwater, Linda CFO Waldo County General Hospital 2075054104	1/14/2019 8:27 AM
Details	Last Recertification Date	Update	Recertification	11/22/2017 10:11:40 AM	8/31/2018 9:51:41 AM	8/31/2018 9:51 AM
Details	Last Recertification Date	Update	Recertification	8/18/2016 12:00:00 AM	11/22/2017 10:11:40 AM	11/22/2017 10:11 AM
Contacts	Authorizing Official	Update		Drinkwater, Linda CFO 2073389304-4104	Drinkwater, Linda CFO Waldo County General Hospital 2073389304-4104	10/3/2017 2:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Needham, Denise Pharmacy Manager Waldo County General Hospital and Pen Bay Medical Center 2079302509	Needham, Denise Regional Director of Pharmacy Waldo County General Hospital and Pen Bay Medical Center 2079218577	10/2/2017 8:56 AM
Contacts	Primary Contact	Update		Needham, Denise Pharmacy Manager 2079302509	Needham, Denise Pharmacy Manager Waldo County General Hospital and Pen Bay Medical Center 2079302509	10/2/2017 8:45 AM
Contacts	Primary Contact	Update		Jurewitz, Thomas P. DIRECTOR OF PHARMACY 2079218577	Needham, Denise Pharmacy Manager 2079302509	5/23/2017 12:58 PM
Contacts	Authorizing Official	Insert			Drinkwater, Linda CFO 2073389304-4104	5/23/2017 12:37 PM
Contacts	Signed By	Insert			KELLY, MAURA CFO 2075946721	5/23/2017 12:37 PM
Addresses	Main Address	Insert			68 Ben Paul Lane Rockport, ME 04856	5/1/2017 1:51 PM
Details	Last Recertification Date	Update		8/7/2015 12:00:00 AM	8/18/2016 12:00:00 AM	8/18/2016 1:53 PM
Contacts	Primary Contact	Insert			Jurewitz, Thomas P. DIRECTOR OF PHARMACY 2079218577	10/2/2015 7:53 PM
Details	Last Recertification Date	Update		8/22/2014 12:00:00 AM	8/7/2015 12:00:00 AM	8/7/2015 2:42 PM
Medicaid Billing	Medicaid: Number	Update		1982645303	1982645305	7/10/2015 4:04 PM
Medicaid Billing	NPI: Number	Update		1982645303	1982645305	7/10/2015 4:04 PM
Details	Last Recertification Date	Update			8/22/2014 12:00:00 AM	8/22/2014 8:11 AM
Dates	Participating Approval Date	Update			9/11/2013 12:00:00 AM	9/11/2013 6:14 PM
Details	State	Update		Pending	Active	9/11/2013 6:14 PM
Dates	Start Date	Update			10/1/2013 12:00:00 AM	9/11/2013 6:14 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	DSH200063S	8/9/2013 8:13 AM
Details	Entity Subname	Update		Penobscot Bay Otolaryngology - Dr. Charles Kava	Penobscot Bay Otolaryngology - Dr. Charles Kava, Clinic	8/9/2013 8:13 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	7/5/2013 10:51 AM
Medicaid Billing	Medicaid: Number	Insert			1982645303	7/5/2013 10:51 AM
Medicaid Billing	Medicaid: State	Insert			ME	7/5/2013 10:51 AM
Medicaid Billing	NPI: Number	Insert			1982645303	7/5/2013 10:51 AM
Details	Last Recertification Date	Insert				7/5/2013 10:51 AM
Details	Grant Number	Insert				7/5/2013 10:51 AM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	7/5/2013 10:51 AM
Details	Is Authorizing Official EHB Data	Insert				7/5/2013 10:51 AM
Dates	Last Date That 340B Drugs Purchased	Insert				7/5/2013 10:51 AM
Details	Medicare Provider Number	Insert			200063	7/5/2013 10:51 AM
Details	Entity Name	Insert			PENOBSCOT BAY MEDICAL CENTER	7/5/2013 10:51 AM
Details	Program Code	Insert			DSH	7/5/2013 10:51 AM
Details	Entity Subname	Insert			Penobscot Bay Otolaryngology - Dr. Charles Kava	7/5/2013 10:51 AM
Dates	Participating Approval Date	Insert				7/5/2013 10:51 AM
Details	State	Insert			Pending	7/5/2013 10:51 AM
Dates	Registration Date	Insert			7/5/2013 12:00:00 AM	7/5/2013 10:51 AM
Dates	Signed By Date	Insert			7/5/2013 12:00:00 AM	7/5/2013 10:51 AM
Dates	Start Date	Insert				7/5/2013 10:51 AM
Terminations	Termination Comments	Insert				7/5/2013 10:51 AM
Terminations	Termination Date	Insert				7/5/2013 10:51 AM
Terminations	Termination Effective Date	Insert				7/5/2013 10:51 AM
Terminations	Termination Reason	Insert				7/5/2013 10:51 AM