Covered Entity Details

CAH201312-24 MAINEHEALTH WALDO HOSPITAL (Active) - information as of 5/6/2025 11:07:10 PM

Main Details

Name

MAINEHEALTH WALDO HOSPITAL

Subdivision Name

WCMP Anticoagulation Clinic

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH201312-24

Medicare Provider Number

201312

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/12/2018

Participating Start Date

7/1/2018

Participating Approval Date

5/25/2018

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

119 Northport Ave, Suite 240
Biscone Building, Second Floor
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 8:22:02 AM	8/24/2024 10:17:12 AM	8/24/2024 10:17 AM
Details	Last Recertification Date	Update	Recertification	8/29/2022 8:16:25 AM	8/29/2023 8:22:02 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 12:03:33 PM	8/29/2022 8:16:25 AM	8/29/2022 8:16 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 3:45:07 PM	8/19/2021 12:03:33 PM	8/19/2021 12:03 PM
Medicaid Billing	NPI: Number	Insert	Recertification		1265912075	8/26/2020 3:45 PM
Medicaid Billing	NPI: State	Insert	Recertification		ME	8/26/2020 3:45 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1265912075 ( )		8/26/2020 3:45 PM
Details	Last Recertification Date	Update	Recertification	8/25/2019 11:54:11 AM	8/26/2020 3:45:07 PM	8/26/2020 3:45 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 5:18 PM
Addresses	Main Address	Update	Change Request	119 Northport Ave Suite 240 Second Floor Belfast, ME 04915	119 Northport Ave, Suite 240 Biscone Building, Second Floor Belfast, ME 04915	10/29/2019 6:59 AM
Details	Entity Subname	Update	Change Request	WCMP Anticoagulation Clinic - Anticoagulation	WCMP Anticoagulation Clinic	10/29/2019 6:59 AM
Details	Last Recertification Date	Update	Recertification	8/31/2018 9:57:01 AM	8/25/2019 11:54:11 AM	8/25/2019 11:54 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
Contacts	Signed By	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 8:24 AM
Medicaid Billing	NPI: Number	Update	Change Request	1841397932	1265912075	1/14/2019 8:24 AM
Details	Last Recertification Date	Update	Recertification		8/31/2018 9:57:01 AM	8/31/2018 9:57 AM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Signed By	Insert	New Registration		Drinkwater, Linda CFO Waldo County General Hospital 2073389304-4104	5/25/2018 1:29 PM
Details	340B ID	Update	New Registration		CAH201312-24	5/25/2018 1:29 PM
Details	Entity Subname	Update	New Registration	WCMP Anticoagulation Clinic	WCMP Anticoagulation Clinic - Anticoagulation	5/25/2018 1:29 PM
Dates	Participating Approval Date	Update	New Registration		5/25/2018 1:29:56 PM	5/25/2018 1:29 PM
Details	State	Update	New Registration	Pending	Approved	5/25/2018 1:29 PM
Dates	Signed By Date	Update	New Registration		4/13/2018 2:20:28 PM	5/25/2018 1:29 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	5/25/2018 1:29 PM
Addresses	Main Address	Insert	New Registration		119 Northport Ave Suite 240 Second Floor Belfast, ME 04915	4/12/2018 8:35 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/12/2018 8:35 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		01-0177170	4/12/2018 8:35 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		ME	4/12/2018 8:35 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1841397932	4/12/2018 8:35 AM
Contacts	Authorizing Official	Insert	New Registration		Drinkwater, Linda CFO Waldo County General Hospital 2073389304-4104	4/12/2018 8:35 AM
Contacts	Primary Contact	Insert	New Registration		Needham, Denise Regional Director of Pharmacy Waldo County General Hospital and Pen Bay Medical Center 2079218577	4/12/2018 8:35 AM
Details	Last Recertification Date	Insert	New Registration			4/12/2018 8:35 AM
Details	Grant Number	Insert	New Registration			4/12/2018 8:35 AM
Details	340B ID	Insert	New Registration			4/12/2018 8:35 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/12/2018 8:35 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/12/2018 8:35 AM
Details	Medicare Provider Number	Insert	New Registration		201312	4/12/2018 8:35 AM
Details	Entity Name	Insert	New Registration		WALDO COUNTY GENERAL HOSPITAL	4/12/2018 8:35 AM
Details	Program Code	Insert	New Registration		CAH	4/12/2018 8:35 AM
Details	Entity Subname	Insert	New Registration		WCMP Anticoagulation Clinic	4/12/2018 8:35 AM
Dates	Participating Approval Date	Insert	New Registration			4/12/2018 8:35 AM
Details	State	Insert	New Registration		Pending	4/12/2018 8:35 AM
Dates	Registration Date	Insert	New Registration		4/12/2018 8:35:55 AM	4/12/2018 8:35 AM
Dates	Signed By Date	Insert	New Registration			4/12/2018 8:35 AM
Dates	Start Date	Insert	New Registration			4/12/2018 8:35 AM
Terminations	Termination Comments	Insert	New Registration			4/12/2018 8:35 AM
Terminations	Termination Date	Insert	New Registration			4/12/2018 8:35 AM
Terminations	Termination Effective Date	Insert	New Registration			4/12/2018 8:35 AM
Terminations	Termination Reason	Insert	New Registration			4/12/2018 8:35 AM