Covered Entity Details

CAH201312-19 MAINEHEALTH WALDO HOSPITAL (Active) - information as of 6/28/2025 12:24:38 AM

Main Details

Name

MAINEHEALTH WALDO HOSPITAL

Subdivision Name

WCMP Nephrology

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH201312-19

Medicare Provider Number

201312

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2017

Participating Start Date

7/1/2017

Participating Approval Date

5/8/2017

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

125 Northport Ave, Suite 106
Belfast, ME 04915

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	1841397932

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
CAH201312-01	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Arthur Jewell Community Health Center	55 Reynolds Rd	Brooks	ME	Active
CAH201312-02	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Stockton Springs Regional Health Center	11 Cape Jellison Rd	Stockton Springs	ME	Active
CAH201312-03	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Physical and Integrative Medicine	37 Mortland Rd	Searsport	ME	Active
CAH201312-04	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Donald S Walker Health Center	43 West Main Street	Liberty	ME	Active
CAH201312-05	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Lincolnville Regional Health Center	2399 Atlantic Hwy	Lincolnville	ME	Active
CAH201312-06	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Cardiovascular Medicine	116 Northport Ave, Suite 210	Belfast	ME	Active
CAH201312-07	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Diabetes Services	16 Fahy St	Belfast	ME	Active
CAH201312-08	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Primary & Walk-In Care	119 Northport Avenue	Belfast	ME	Active
CAH201312-09	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Ear, Nose, and Throat	116 Northport Ave, Suite 118	Belfast	ME	Active
CAH201312-10	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Urology	125 Northport Ave	Belfast	ME	Active
CAH201312-11	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Rheumatology	116 Northport Ave, Suite 220	Belfast	ME	Active
CAH201312-12	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Pulmonology	116 Northport Ave, Suite 218	Belfast	ME	Active
CAH201312-13	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Podiatry	16 Fahy St, Suite 201	Belfast	ME	Active
CAH201312-14	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCGH Oncology	116 Northport Ave, Suite 112	Belfast	ME	Active
CAH201312-15	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Neurology	16 Fahy St, Suite 102	Belfast	ME	Active
CAH201312-16	Child	CAH	WALDO COUNTY GENERAL HOSPITAL	WCMP Dermatology Associates	16 Fahy St, Suite 202	Belfast	ME	Terminated
CAH201312-17	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Women's Health	16 Fahy St, Suite 108	Belfast	ME	Active
CAH201312-18	Child	CAH	WALDO COUNTY GENERAL HOSPITAL	WCMP Primary Care-16 Fahy St	16 Fahy St, Suite 103	Belfast	ME	Terminated
CAH201312-19	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Nephrology	125 Northport Ave, Suite 106	Belfast	ME	Active
CAH201312-20	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Orthopedics and Sports Medicine	116 Northport Ave, Suite 214	Belfast	ME	Active
CAH201312-21	Child	CAH	WALDO COUNTY GENERAL HOSPITAL	WCMP General Surgery	16 Fahy St, Suite 202	Belfast	ME	Terminated
CAH201312-22	Child	CAH	WALDO COUNTY GENERAL HOSPITAL	WCMP Surgical Services	16 Fahy St, Suite 202	Belfast	ME	Terminated
CAH201312-23	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Surgical Associates	16 Fahy St, Suite 202	Belfast	ME	Active
CAH201312-24	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Anticoagulation Clinic	119 Northport Ave, Suite 240	Belfast	ME	Active
CAH201312-25	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Family Medicine	9 Fahy St	Belfast	ME	Active
CAH201312-26	Child	CAH	WALDO COUNTY GENERAL HOSPITAL	WCMP RESPIRATORY HEALTH CENTER - Respiratory	125 NORTHPORT AVE	Belfast	ME	Terminated
CAH201312-27	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCMP Palliative Care - WCMP Palliative Care	125 Northport Ave	Belfast	ME	Active
CAH201312-28	Child	CAH	MAINEHEALTH WALDO HOSPITAL	WCGH Wound Clinic - WCGH Wound Clinic	16 Fahy St	Belfast	ME	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
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 8:27:07 AM	8/24/2024 10:21:32 AM	8/24/2024 10:21 AM
Addresses	Main Address	Update	Change Request	125 Northport Ave, Suite 106 Ste 216 Belfast, ME 04915	125 Northport Ave, Suite 106 Belfast, ME 04915	9/19/2023 8:26 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 8:19:30 AM	8/29/2023 8:27:07 AM	8/29/2023 8:27 AM
Addresses	Main Address	Update	Change Request	116 Northport Ave Ste 216 Belfast, ME 04915	125 Northport Ave, Suite 106 Ste 216 Belfast, ME 04915	3/29/2023 4:18 PM
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 12:12:44 PM	8/29/2022 8:19:30 AM	8/29/2022 8:19 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	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 1:42 PM
Details	Last Recertification Date	Update	Recertification	8/26/2020 3:44:37 PM	8/19/2021 12:12:44 PM	8/19/2021 12:12 PM
Addresses	Main Address	Update	Change Request	16 Fahy St, Suite 202 Cobb Medical Building, First Floor Belfast, ME 04915	116 Northport Ave Ste 216 Belfast, ME 04915	12/14/2020 8:07 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265912075	8/26/2020 3:44 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/26/2020 3:44 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265912075 ( )		8/26/2020 3:44 PM
Details	Last Recertification Date	Update	Recertification	8/25/2019 11:56:05 AM	8/26/2020 3:44:37 PM	8/26/2020 3:44 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 5:17 PM
Addresses	Main Address	Update	Change Request	125 Northport Ave, Suite 101 Belfast, ME 04915	16 Fahy St, Suite 202 Cobb Medical Building, First Floor Belfast, ME 04915	10/29/2019 7:01 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 9:53:52 AM	8/25/2019 11:56:05 AM	8/25/2019 11:56 AM
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 8:18 AM
Medicaid Billing	NPI: Number	Update	Change Request	1841397932	1265912075	1/14/2019 8:18 AM
Details	Last Recertification Date	Update	Recertification	11/22/2017 10:10:26 AM	8/31/2018 9:53:52 AM	8/31/2018 9:53 AM
Medicaid Billing	Medicaid: Number	Update	Recertification	101570000	01-0177170	11/22/2017 10:10 AM
Details	Last Recertification Date	Update	Recertification		11/22/2017 10:10:26 AM	11/22/2017 10:10 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	Insert			Needham, Denise Pharmacy Manager 2079302509	5/23/2017 12:58 PM
Addresses	Main Address	Insert			125 Northport Ave, Suite 101 Belfast, ME 04915	5/8/2017 5:02 PM
Dates	Participating Approval Date	Update			5/8/2017 12:00:00 AM	5/8/2017 5:01 PM
Details	State	Update		Pending	Active	5/8/2017 5:01 PM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	5/8/2017 5:01 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_76688	CAH201312-19	5/8/2017 11:10 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_76688	4/12/2017 1:49 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/12/2017 1:49 PM
Medicaid Billing	Medicaid: Number	Insert			101570000	4/12/2017 1:49 PM
Medicaid Billing	Medicaid: State	Insert			ME	4/12/2017 1:49 PM
Medicaid Billing	NPI: Number	Insert			1841397932	4/12/2017 1:49 PM
Details	Last Recertification Date	Insert				4/12/2017 1:49 PM
Details	Grant Number	Insert				4/12/2017 1:49 PM
Details	340B ID	Insert				4/12/2017 1:49 PM
Details	Is Authorizing Official EHB Data	Insert				4/12/2017 1:49 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/12/2017 1:49 PM
Details	Medicare Provider Number	Insert			201312	4/12/2017 1:49 PM
Details	Entity Name	Insert			WALDO COUNTY GENERAL HOSPITAL	4/12/2017 1:49 PM
Details	Program Code	Insert			CAH	4/12/2017 1:49 PM
Details	Entity Subname	Insert			WCMP Nephrology	4/12/2017 1:49 PM
Dates	Participating Approval Date	Insert				4/12/2017 1:49 PM
Details	State	Insert			Pending	4/12/2017 1:49 PM
Dates	Registration Date	Insert			4/12/2017 12:00:00 AM	4/12/2017 1:49 PM
Dates	Signed By Date	Insert			4/12/2017 12:00:00 AM	4/12/2017 1:49 PM
Dates	Start Date	Insert				4/12/2017 1:49 PM
Terminations	Termination Comments	Insert				4/12/2017 1:49 PM
Terminations	Termination Date	Insert				4/12/2017 1:49 PM
Terminations	Termination Effective Date	Insert				4/12/2017 1:49 PM
Terminations	Termination Reason	Insert				4/12/2017 1:49 PM