| Details | Entity Name | Update | Change Request | WALDO COUNTY GENERAL HOSPITAL | MAINEHEALTH WALDO HOSPITAL | 3/19/2025 12:56 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2023 8:22:59 AM | 8/24/2024 10:15:37 AM | 8/24/2024 10:15 AM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2022 8:11:57 AM | 8/29/2023 8:22:59 AM | 8/29/2023 8:22 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 4:02 PM |
| Details | Last Recertification Date | Update | Recertification | 8/19/2021 12:10:31 PM | 8/29/2022 8:11:57 AM | 8/29/2022 8:11 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 9:54 AM |
| Medicaid Billing | NPI: Number | Delete | Group Change Request | 1265912075 (ME) | | 10/15/2021 7:35 AM |
| Medicaid Billing | NPI: Number | Insert | Group Change Request | | 1841397932 | 10/15/2021 7:35 AM |
| Medicaid Billing | NPI: State | Insert | Group Change Request | | ME | 10/15/2021 7:35 AM |
| Contacts | Primary Contact | Update | Change Request | MacMillan, David
Director of Pharmacy
Waldo County General Hospital
2073018563 | Hoang, Minh
Director of 340B and Drug Supply Management
Maine Health
2076628064 | 8/31/2021 4:32 PM |
| Details | Last Recertification Date | Update | Recertification | 8/26/2020 3:49:31 PM | 8/19/2021 12:10:31 PM | 8/19/2021 12:10 PM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1265912075 | 8/26/2020 3:49 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | ME | 8/26/2020 3:49 PM |
| Medicaid Billing | NPI: Number | Delete | Recertification | 1265912075 ( ) | | 8/26/2020 3:49 PM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2019 12:08:46 PM | 8/26/2020 3:49:31 PM | 8/26/2020 3:49 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 | 4/9/2020 5:14 PM |
| Addresses | Main Address | Update | Change Request |
116 Northport Ave, Suite 220
Belfast, ME 04915 |
116 Northport Ave, Suite 220
Ludwig Medical Building, First Floor
Belfast, ME 04915 | 10/29/2019 7:04 AM |
| Details | Last Recertification Date | Update | Recertification | 8/31/2018 9:48:51 AM | 8/25/2019 12:08:46 PM | 8/25/2019 12:08 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 |
| Medicaid Billing | Medicaid: Number | Update | Change Request | 01-0177170 | 01-0238552 | 1/14/2019 8:26 AM |
| Medicaid Billing | NPI: Number | Update | Change Request | 1841397932 | 1265912075 | 1/14/2019 8:26 AM |
| Details | Last Recertification Date | Update | Recertification | 11/22/2017 10:04:25 AM | 8/31/2018 9:48:51 AM | 8/31/2018 9:48 AM |
| Addresses | Main Address | Update | Change Request |
16 Fahy St, Suite 202
Cobb Medical Building
Belfast, ME 04915 |
116 Northport Ave, Suite 220
Belfast, ME 04915 | 4/13/2018 3:10 PM |
| Medicaid Billing | Medicaid: Number | Update | Recertification | 101570000 | 01-0177170 | 11/22/2017 10:04 AM |
| Details | Last Recertification Date | Update | Recertification | 8/12/2016 12:00:00 AM | 11/22/2017 10:04:25 AM | 11/22/2017 10:04 AM |
| Contacts | Authorizing Official | Insert | AO Change Request | | Drinkwater, Linda
CFO
Waldo County General Hospital
2073389304-4104 | 11/15/2017 7:29 AM |
| 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 | Signed By | Insert | | | DRINKWATER, LINDA
CHIEF FINANCIAL OFFICER
2073382500-4104 | 5/23/2017 12:58 PM |
| Contacts | Primary Contact | Update | | Hurley, Brooks
Director of Pharmacy
2079302509-4351 | Needham, Denise
Pharmacy Manager
2079302509 | 5/23/2017 12:58 PM |
| Addresses | Main Address | Insert | | |
16 Fahy St, Suite 202
Cobb Medical Building
Belfast, ME 04915 | 5/23/2017 12:39 PM |
| Details | Entity Subname | Update | | Waldo County Medical Partners Rheumatology / Waldo County Medical Partners Rheumatology | WCMP Rheumatology | 5/23/2017 12:39 PM |
| Details | Last Recertification Date | Update | | 8/11/2015 12:00:00 AM | 8/12/2016 12:00:00 AM | 8/12/2016 12:44 PM |
| Medicaid Billing | Medicaid: Number | Update | | 201312 | 101570000 | 8/11/2015 12:09 PM |
| Details | Last Recertification Date | Update | | | 8/11/2015 12:00:00 AM | 8/11/2015 12:09 PM |
| Contacts | Primary Contact | Insert | | | Hurley, Brooks
Director of Pharmacy
2079302509-4351 | 5/20/2015 11:47 AM |
| Dates | Participating Approval Date | Update | | | 5/20/2015 12:00:00 AM | 5/20/2015 11:45 AM |
| Details | State | Update | | Pending | Active | 5/20/2015 11:45 AM |
| Dates | Start Date | Update | | | 7/1/2015 12:00:00 AM | 5/20/2015 11:45 AM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_50911 | CAH201312-11 | 4/13/2015 10:53 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_50911 | 4/8/2015 7:12 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/8/2015 7:12 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 201312 | 4/8/2015 7:12 PM |
| Medicaid Billing | Medicaid: State | Insert | | | ME | 4/8/2015 7:12 PM |
| Medicaid Billing | NPI: Number | Insert | | | 1841397932 | 4/8/2015 7:12 PM |
| Details | Last Recertification Date | Insert | | | | 4/8/2015 7:12 PM |
| Details | Grant Number | Insert | | | | 4/8/2015 7:12 PM |
| Details | 340B ID | Insert | | | | 4/8/2015 7:12 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/8/2015 7:12 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/8/2015 7:12 PM |
| Details | Medicare Provider Number | Insert | | | 201312 | 4/8/2015 7:12 PM |
| Details | Entity Name | Insert | | | WALDO COUNTY GENERAL HOSPITAL | 4/8/2015 7:12 PM |
| Details | Program Code | Insert | | | CAH | 4/8/2015 7:12 PM |
| Details | Entity Subname | Insert | | | Waldo County Medical Partners Rheumatology / Waldo County Medical Partners Rheumatology | 4/8/2015 7:12 PM |
| Dates | Participating Approval Date | Insert | | | | 4/8/2015 7:12 PM |
| Details | State | Insert | | | Pending | 4/8/2015 7:12 PM |
| Dates | Registration Date | Insert | | | 4/8/2015 12:00:00 AM | 4/8/2015 7:12 PM |
| Dates | Signed By Date | Insert | | | 4/8/2015 12:00:00 AM | 4/8/2015 7:12 PM |
| Dates | Start Date | Insert | | | | 4/8/2015 7:12 PM |
| Terminations | Termination Comments | Insert | | | | 4/8/2015 7:12 PM |
| Terminations | Termination Date | Insert | | | | 4/8/2015 7:12 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/8/2015 7:12 PM |
| Terminations | Termination Reason | Insert | | | | 4/8/2015 7:12 PM |