Covered Entity Details

CH01458BL Penobscot Community Health Center (Active) - information as of 4/25/2025 8:36:47 PM

Main Details

Name

Penobscot Community Health Center

Subdivision Name

Adult Wellness Center

Type

HRSA-Funded Health Center

Site ID

BPS-H80-003162

340B ID

CH01458BL

Grant Number

H80CS04291

Additional Details

Current Program Status

Active

Registration Date

1/27/2020

Participating Start Date

4/1/2020

Participating Approval Date

2/28/2020

Last Recertification Date

3/6/2025

Contacts

Authorizing Official

Penobscot Community Health Center Inc.
Lorelle Dwyer, President & CEO
(207) 992-9200

Primary Contact

Penobscot Community Health Care
Meagan Rusby, Associate Director of Pharmacy
(207) 992-9200 Ext: 1764

Addresses

Street Address

1068 Union St
Bangor, ME 04401-3016

Billing Address

PENOBSCOT COMMUNITY HEALTH CENTER, INC
103 Maine Ave
BANGOR, ME 04401

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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		1083259410

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
Contract Detail	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	500 STILLWATER AVE	OLD TOWN	ME	04468	04/19/2024	07/01/2024			07/01/2024

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH014580	Active	BPS-H80-008910	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BREWER MEDICAL CENTER	735 WILSON ST	BREWER	ME
CH01458A	Active	BPS-H80-012549	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	DENTAL CENTER	1048 UNION ST	BANGOR	ME
CH01458AA	Terminated	BPS-H80-006789	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	JLH BOARDING HOUSE	87 OHIO STREET	BANGOR	ME
CH01458AB	Terminated	BPS-H80-007081	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	KING'S DAUGHTERS HOME FOR WOMEN	89 OHIO STREET	BANGOR	ME
CH01458AD	Terminated	BPS-H80-006535	PENOBSCOT COMMUNITY HEALTH CENTER, INC	NFI NORTH INC.	60 Ohio St	Bangor	ME
CH01458AG	Active	BPS-H80-006232	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	DIRIGO PINES RETIREMENT COMMUNITY	9 ALUMNI DRIVE	ORONO	ME
CH01458AH	Active	BPS-H80-005796	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	WOODLANDS ASSISTED LIVING BREWER	53 COLONIAL CIR	BREWER	ME
CH01458AK	Active	BPS-H80-006183	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	SUNBURY VILLAGE RETIREMENT RESIDENCE	992 OHIO ST	BANGOR	ME
CH01458AQ	Active	BPS-H80-002199	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BREWER HIGH SCHOOL CLINIC	79 PARKWAY SOUTH	BREWER	ME
CH01458AR	Active	BPS-H80-010558	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BREWER COMMUNITY SCHOOL	92 PENDLETON ST	BREWER	ME
CH01458AT	Terminated	BPS-H80-003628	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	PENOBSCOT COMMUNITY HEALTH CARE	177 COLDBROOK RD	HAMPDEN	ME
CH01458AU	Terminated	BPS-H80-000418	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	SUMMER STREET HEALTH CENTER	34 SUMMER STREET	BANGOR	ME
CH01458AW	Active	BPS-H80-004309	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	CAPEHART COMMUNITY HEALTH CENTER	86 DAVIS ROAD	BANGOR	ME
CH01458AY	Terminated	BPS-H80-000720	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	SUMMER STREET CLINIC - THE OUTBACK	30 SUMMER STREET	BANGOR	ME
CH01458AZ	Active	BPS-H80-032269	Penobscot Community Health Center	992 Admin	992 Union St Ste 3	Bangor	ME
CH01458B	Active	BPS-H80-005152	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	ELIZABETH LEVINSON CENTER	159 HOGAN ROAD	BANGOR	ME
CH01458BA	Active	BPS-H80-004896	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	HELEN HUNT HEALTH CENTER	242 BRUNSWICK STREET	OLD TOWN	ME
CH01458BB	Active	BPS-H80-011120	PENOBSCOT COMMUNITY HEALTH CENTER, INC	ALPHA Program - Brewer High School	261 Center St	Brewer	ME
CH01458BC	Terminated	BPS-H80-012616	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Seaport Community Health Center	41 Wight St	Belfast	ME
CH01458BD	Active	BPS-H80-013395	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Jackman Community Health Center	376 Main St	Jackman	ME
CH01458BE	Terminated	BPS-H80-013481	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Winterport Community Health Center	775 N Main St	Winterport	ME
CH01458BF	Terminated	BPS-H80-013333	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Forest Hills Schools JCHC	606 Main St	Jackman	ME
CH01458BG	Active	BPS-H80-033764	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Seaport Community Health Center	29 Schoodic Dr	Belfast	ME
CH01458BH	Terminated	BPS-H80-005207	PENOBSCOT COMMUNITY HEALTH CENTER	United Cerebral Palsy of Northeastern Maine	700 Mount Hope Ave STE 320	Bangor	ME
CH01458BJ	Active	BPS-H80-008838	PENOBSCOT COMMUNITY HEALTH CENTER	Maine Avenue Administration/Clinical Center	103 Maine Ave	Bangor	ME
CH01458BK	Active	BPS-H80-018173	PENOBSCOT COMMUNITY HEALTH CENTER, INC	Downeast School - PCHC Dental	100 Moosehead Blvd	Bangor	ME
CH01458BL	Active	BPS-H80-003162	Penobscot Community Health Center	Adult Wellness Center	1068 Union St	Bangor	ME
CH01458BM	Active	BPS-H80-035019	Penobscot Community Health Center	Bangor School Department School-Based Health Center	885 Broadway	Bangor	ME
CH01458BN	Active	BPS-H80-037350	PENOBSCOT COMMUNITY HEALTH CENTER	Old Town Elementary School RSU 34	576 Stillwater Ave	Old Town	ME
CH01458BP	Active	BPS-H80-037334	PENOBSCOT COMMUNITY HEALTH CENTER	Old Town High School RSU 34	203 Stillwater Ave	Old Town	ME
CH01458BQ	Active	BPS-H80-037335	PENOBSCOT COMMUNITY HEALTH CENTER	J.A. Leonard Middle School RSU 34	156 Oak St	Old Town	ME
CH01458BR	Active	BPS-H80-038661	PENOBSCOT COMMUNITY HEALTH CENTER	Bangor School Dept. SBHC James F Doughty Middle School	143 Fifth St	Bangor	ME
CH01458BS	Active	BPS-H80-038662	PENOBSCOT COMMUNITY HEALTH CENTER	Bangor School Dept. SBHC William S Cohen Middle School	304 Garland St	Bangor	ME
CH01458C	Active	BPS-H80-003873	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	PENOBSCOT COMMUNITY HEALTH CENTER	1012 UNION STREET	BANGOR	ME
CH01458D	Active	BPS-H80-001061	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	COMMUNITY CARE AND GERIATRICS	992 UNION ST	BANGOR	ME
CH01458E	Active	BPS-H80-009214	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	HOPE HOUSE	181 CORPORATE DR	BANGOR	ME
CH01458G	Active	BPS-H80-007298	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	THE MEADOWS	101 PERKINS AVE	OLD TOWN	ME
CH01458H	Active	BPS-H80-000964	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	EASTSIDE REHAB AND LIVING CENTER	516 MT HOPE AVE	BANGOR	ME
CH01458J	Terminated	BPS-H80-006681	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BANGOR AREA HOMELESS SHELTER	26 CEDAR ST	BANGOR	ME
CH01458L	Active	BPS-H80-001030	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BREWER REHAB AND LIVING CENTER	74 PARKWAY SOUTH	BREWER	ME
CH01458M	Active	BPS-H80-005704	Penobscot Community Health Center	MAINE VETERANS CENTER/HOMES	44 Hogan Rd	Bangor	ME
CH01458N	Active	BPS-H80-007281	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	PHILIPS-STRICKLAND HOUSE	21 BOYD ST	BANGOR	ME
CH01458O	Active	BPS-H80-006411	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	WESTGATE MANOR NURSING HOMES	750 UNION ST	BANGOR	ME
CH01458P	Terminated	BPS-H80-005829	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	TREATS FALLS HOUSE	2 HILLSIDE ROAD	ORONO	ME
CH01458Q	Terminated	BPS-H80-007041	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	STILLWATER HEALTH CARE	335 STILLWATER AVE	BANGOR	ME
CH01458R	Terminated	BPS-H80-007061	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	ROSS MANOR	758 BROADWAY	BANGOR	ME
CH01458S	Active	BPS-H80-005791	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	ORONO COMMONS	117 BENNOCH ROAD	ORONO	ME
CH01458U	Active	BPS-H80-006400	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	BANGOR NURSING AND REHABILITATION CENTER	103 TEXAS AVENUE	BANGOR	ME
CH01458W	Active	BPS-H80-027792	PENOBSCOT COMMUNITY HEALTH CENTER, INC.	PENOBSCOT PEDIATRICS	6 Telcom Drive	BANGOR	ME

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH014580	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/01/2023
CH014580	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/01/2023
CH014580	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	01/01/2023
CH014580	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/01/2023
CH014580	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	01/01/2023
CH014580	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/01/2023
CH014580	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/01/2023
CH014580	APOTHECARY BY DESIGN ACQUISITION CO LLC	DBA:APOTHECARY BY DESIGN	141 PREBLE STREET	PORTLAND	ME	04101	01/01/2017	02/09/2018
CH014580	BANGOR DRUG COMPANY	711 BROADWAY STE 1		BANGOR	ME	04401-3225	04/01/2020
CH014580	BANGOR DRUG LTC	711 BROADWAY STE 2		BANGOR	ME	04401-3225	04/01/2020
CH01458AK	BANGOR DRUG LTC	711 BROADWAY STE 2		BANGOR	ME	04401-3225	07/01/2024
CH014580	BELFAST DRUG COMPANY INC	15 STARRETT DR UNIT G		BELFAST	ME	04915-6563	10/01/2023
CH01458AH	BELFAST DRUG COMPANY INC	15 STARRETT DR UNIT G		BELFAST	ME	04915-6563	07/01/2024
CH014580	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	07/01/2024
CH014580	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	13925 YALE AVE STE 145		IRVINE	CA	92620-2670	07/01/2024
CH014580	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	07/01/2024
CH014580	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	07/01/2024
CH014580	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	07/01/2024
CH014580	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	01/01/2022
CH014580	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	01/01/2022
CH014580	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	01/01/2022
CH014580	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	01/01/2022
CH014580	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	01/01/2022
CH014580	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	01/01/2022
CH014580	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	01/01/2022
CH014580	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	01/01/2022
CH014580	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	01/01/2022
CH014580	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	01/01/2022
CH014580	COMMUNITY PHARMACY OF BUCKSPORT	75 MAIN ST.		BUCKSPORT	ME	04416	04/01/2022
CH01458AQ	COMMUNITY PHARMACY OF BUCKSPORT	75 MAIN ST.		BUCKSPORT	ME	04416	07/01/2024
CH01458C	COMMUNITY PHARMACY OF CORINTH	689 MAIN ST.		CORINTH	ME	04427	05/12/2011
CH014580	COMMUNITY PHARMACY OF CORINTH	689 MAIN ST.		CORINTH	ME	04427	07/01/2013
CH01458R	COMMUNITY PHARMACY OF CORINTH	689 MAIN ST.		CORINTH	ME	04427	10/01/2024	01/01/2025
CH014580	COMMUNITY PHARMACY-HERMON	2402 ROUTE 2	UNIT 1	HERMON	ME	04401-0666	04/01/2022
CH014580	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	07/01/2021
CH014580	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	07/01/2021
CH014580	CVS STATE CAPITAL, L.L.C.	CVS PHARMACY # 16975	60 LONGVIEW DR	BANGOR	ME	04401	10/01/2019
CH01458W	CVS STATE CAPITAL, L.L.C.	CVS PHARMACY # 16975	60 LONGVIEW DR	BANGOR	ME	04401	07/01/2024
CH014580	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	01/01/2022
CH014580	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/01/2021
CH014580	DOGWOOD PHARMACY LLC	D/B/A MEDSCRIPTS MEDICAL PHARMACY	1325 MILLER RD STE K	GREENVILLE	SC	29607-6541	07/01/2024
CH014580	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	01/01/2023
CH014580	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	01/01/2023
CH014580	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	01/01/2023
CH014580	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	01/01/2023
CH01458AG	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/01/2024
CH014580	GENOA HEALTHCARE LLC	42 CEDAR STREET		BANGOR	ME	04401	01/01/2023
CH014580	GENOA HEALTHCARE LLC	2 SPRINGBROOK DR STE 101		BIDDEFORD	ME	04005	01/01/2023	06/15/2023
CH01458A	GENOA HEALTHCARE LLC	42 CEDAR STREET		BANGOR	ME	04401	07/01/2024
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	383 WILSON ST	BREWER	ME	04412	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	1133 UNION ST	BANGOR	ME	04401	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	843 CENTRAL STREET	MILLINOCKET	ME	04462-2125	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #84	77 WESTERN AVENUE	HAMPDEN	ME	04444	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	22 GODING AVE	LINCOLN	ME	04457	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD FOOD & DRUG #8330	100 FAIRGROUNDS MARKETPLACE	SKOWHEGAN	ME	04976	10/01/2020	08/11/2024
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	145 ELM STREET	CAMDEN	ME	04843	10/01/2020	08/11/2024
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	653 BROADWAY	BANGOR	ME	04401	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #84	37 CHURCH STREET	DEXTER	ME	04930	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #82	93 LINCOLNVILLE AVE	BELFAST	ME	04915	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	500 STILLWATER AVE	OLD TOWN	ME	04468	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	STE 1 225 HIGH ST	ELLSWORTH	ME	04605	10/01/2020
CH014580	HANNAFORD BROS. CO., LLC	DBA SUPERMARKET & PHARMACY #8443	44 MOOSEHEAD TRAIL	NEWPORT	ME	04953	10/01/2020
CH01458BL	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	500 STILLWATER AVE	OLD TOWN	ME	04468	07/01/2024
CH01458G	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	22 GODING AVE	LINCOLN	ME	04457	10/01/2024
CH01458L	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	STE 1 225 HIGH ST	ELLSWORTH	ME	04605	10/01/2024
CH01458AR	HANNAFORD BROS. CO., LLC	DBA SUPERMARKET & PHARMACY #8443	44 MOOSEHEAD TRAIL	NEWPORT	ME	04953	10/01/2024
CH01458S	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #84	77 WESTERN AVENUE	HAMPDEN	ME	04444	10/01/2024
CH01458BE	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #82	93 LINCOLNVILLE AVE	BELFAST	ME	04915	10/01/2024	01/01/2025
CH01458H	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	653 BROADWAY	BANGOR	ME	04401	10/01/2024
CH01458BK	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	383 WILSON ST	BREWER	ME	04412	10/01/2024
CH01458AW	HANNAFORD BROS. CO., LLC	DBA HANNAFORD SUPERMARKET & PHARMACY #81	1133 UNION ST	BANGOR	ME	04401	10/01/2024
CH014580	M DRUG LLC	DBA NORTHERN LIGHT PHARMACY	70 BENNETT ST	BANGOR	ME	04401	04/01/2015	08/29/2018
CH014580	M DRUG LLC	DBA NORTHERN LIGHT PHARMACY LTC	401 N MAIN ST	BREWER	ME	04412-1802	08/29/2018	09/27/2019
CH014580	M DRUG LLC	DBA NORTHERN LIGHT PHARMACY	70 BENNETT ST	BANGOR	ME	04401	10/02/2019
CH014580	M DRUG LLC DBA MILLER DRUG LTC		208 STATE STREET	BANGOR	ME	04401	01/01/2014	09/27/2019
CH014580	M DRUG LLC DBA MILLER DRUG RIVERSIDE		417 STATE STREET, SUITE 130	BANGOR	ME	04401	09/07/2012
CH014580	M DRUG LLC DBA MILLER DRUG STATE STREET		210 STATE STREET	BANGOR	ME	04401	09/07/2012
CH01458B	M DRUG LLC DBA MILLER DRUG STATE STREET		210 STATE STREET	BANGOR	ME	04401	07/01/2024
CH014580	M DRUG LLC DBA MILLER DRUG WESTGATE		915 UNION STREET SUITE 7	BANGOR	ME	04401	09/07/2012
CH014580	M DRUG LLC DBA MILLER DRUG WHITING HILL		33 WHITING HILL ROAD SUITE 4	BREWER	ME	04412	09/07/2012
CH014580	MAXI DRUG NORTH, INC.	RITE AID #10305	566 UNION STREET	BANGOR	ME	04401	07/01/2013	02/09/2018
CH01458W	MAXI DRUG NORTH, INC.	RITE AID #10305	566 UNION STREET	BANGOR	ME	04401	04/01/2013	02/09/2018
CH014580	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	01/01/2023	06/15/2023
CH014580	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/01/2023	06/15/2023
CH014580	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/01/2023	06/15/2023
CH01458C	ORONO PHARMACY	16 MILL STREET		ORONO	ME	04473	05/12/2011	09/27/2019
CH014580	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/01/2021	10/04/2022
CH014580	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	01/01/2022
CH014580	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #48611	141 PREBLE STREET	PORTLAND	ME	04101	04/01/2018
CH014580	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	01/01/2022
CH014580	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY OR CARELONRX SPECIALTY	ONE WATERFRONT PLAZA 500 ALA MOANA BLVD., BLDG 1	HONOLULU	HI	96813	01/01/2022
CH014580	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	01/01/2022
CH014580	RAINA RX LLC	DBA ROUTE 300 PHARMACY	1208 ROUTE 300 SUITE 103	NEWBURGH	NY	12550	07/01/2024
CH014580	RITE AID OF MAINE, INC.	RITE AID #3279	422 WILSON STREET	BREWER	ME	04412	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #3295	302 MAIN STREET	OLD TOWN	ME	04468	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #3299	36 MOOSEHEAD TRAIL	NEWPORT	ME	04953	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #3897	35 PARK STREET	MILO	ME	04463	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #4262	65 WESTERN AVE	HAMPDEN	ME	04444	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #3296	713 BROADWAY	BANGOR	ME	04401	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #3293	226 UNION STREET	BANGOR	ME	04401	07/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #4149	254 MAIN STREET	BELFAST	ME	04915	10/01/2013	02/09/2018
CH01458W	RITE AID OF MAINE, INC.	RITE AID #3293	226 UNION STREET	BANGOR	ME	04401	04/01/2013	02/09/2018
CH01458W	RITE AID OF MAINE, INC.	RITE AID #3296	713 BROADWAY	BANGOR	ME	04401	04/01/2013	02/09/2018
CH014580	RITE AID OF MAINE, INC.	RITE AID #4171	220 US ROUTE 1 STE 1 PO BOX B1	BUCKSPORT	ME	04416	04/01/2019	03/14/2019
CH014580	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	07/01/2024
CH014580	SANTA BARBARA SPECIALTY PHARMACY LLC	4690 CARPINTERIA AVE STE B		CARPINTERIA	CA	93013	07/01/2024
CH014580	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/01/2017
CH014580	WAL-MART PHARMACY 10-1856	900 STILLWATER AVENUE		BANGOR	ME	04401	03/05/2012
CH01458N	WAL-MART PHARMACY 10-1856	900 STILLWATER AVENUE		BANGOR	ME	04401	10/01/2024
CH014580	WAL-MART PHARMACY 10-1919	250 WEST BROADWAY		LINCOLN	ME	04457	10/01/2015
CH01458BN	WAL-MART PHARMACY 10-1919	250 WEST BROADWAY		LINCOLN	ME	04457	10/01/2024
CH014580	WAL-MART PHARMACY 10-2047	1573 MAIN STREET		PALMYRA	ME	04965	10/01/2015
CH014580	WAL-MART PHARMACY 10-5076	24 WALTON DR		BREWER	ME	04412	03/05/2012
CH01458E	WAL-MART PHARMACY 10-5076	24 WALTON DR		BREWER	ME	04412	07/01/2024
CH01458BM	WAL-MART PHARMACY 10-5076	24 WALTON DR		BREWER	ME	04412	10/01/2024
CH014580	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/01/2017
CH014580	WALGREEN EASTERN CO., INC	WALGREENS #17355	66 MOOSEHEAD TRL	NEWPORT	ME	04953	02/21/2018
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11285	706 BROADWAY	BANGOR	ME	04401	10/01/2013
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11545	437 WILSON ST	BREWER	ME	04412	10/01/2013
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11742	226 HIGH STREET	ELLSWORTH	ME	04605-1742	10/01/2013
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #12818	97 OAK ST	BANGOR	ME	04401-6516	10/01/2013	06/01/2020
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #13615	268 MAIN ST	BELFAST	ME	04915	10/01/2013
CH014580	WALGREEN EASTERN CO., INC.	RITE AID #03293	226 UNION ST	BANGOR	ME	04401	02/21/2018	06/25/2019
CH014580	WALGREEN EASTERN CO., INC.	RITE AID #04149	254 MAIN ST	BELFAST	ME	04915	02/21/2018	06/08/2018
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #18000	302 MAIN ST	OLD TOWN	ME	04468	02/21/2018
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #19253	35 PARK ST	MILO	ME	04463-1152	02/21/2018
CH014580	WALGREEN EASTERN CO., INC.	RITE AID #03279	422 WILSON ST	BREWER	ME	04412	02/21/2018	06/04/2018
CH014580	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #17141	566 UNION ST	BANGOR	ME	04401	02/21/2018
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #18112	65 WESTERN AVE	HAMPDEN	ME	04444-1423	02/21/2018
CH014580	WALGREEN EASTERN CO., INC.	RITE AID #03296	713 BROADWAY	BANGOR	ME	04401	02/21/2018	05/29/2018
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #17149	220 US ROUTE 1	BUCKSPORT	ME	04416	04/01/2019
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #17523	35 ELM ST	CAMDEN	ME	04843	07/01/2019
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #17139	225 MADISON AVE	SKOWHEGAN	ME	04976-2054	07/01/2019
CH014580	WALGREEN EASTERN CO., INC.	WALGREENS #17708	17 SOUTH ST	BLUE HILL	ME	04614-6109	01/01/2022
CH01458BD	WALGREEN EASTERN CO., INC.	DBA: WALGREENS #11545	437 WILSON ST	BREWER	ME	04412	07/01/2024
CH014580	Walgreens Central Fill #21400	44 Cabot Blvd.		Mansfield	MA	02048	04/01/2023
CH014580	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	10/01/2013	07/08/2015
CH014580	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	10/01/2013	07/08/2015
CH014580	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/01/2021
CH014580	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/01/2021	10/10/2023
CH014580	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/01/2021
CH014580	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/01/2021
CH014580	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/01/2023
CH014580	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	McGrady, Frank R Executive Clinical Director of Pharmacy Penobscot Community Health Center Inc 2079929200-1539	Rusby, Meagan Associate Director of Pharmacy Penobscot Community Health Care 2079929200-1764	3/31/2025 6:59 AM
Details	Last Recertification Date	Update	Recertification	2/9/2024 7:48:00 AM	3/6/2025 2:32:24 PM	3/6/2025 2:32 PM
Addresses	Billing Address	Update	Change Request	PENOBSCOT COMMUNITY HEALTH CENTER, INC PO BOX 2100 BANGOR, ME 04401	PENOBSCOT COMMUNITY HEALTH CENTER, INC 103 Maine Ave BANGOR, ME 04401	12/9/2024 1:56 PM
Addresses	Shipping Address	Delete	Change Request	PENOBSCOT COMMUNITY HEALTH CENTER, INC 1012 UNION STREET SUITE 1 BANGOR, ME 04401		12/9/2024 1:56 PM
Contacts	Primary Contact	Update	Profile Change Request	McGrady, Frank R Director of Pharmacy Penobscot Community Health Center Inc 2079929200-1539	McGrady, Frank R Executive Clinical Director of Pharmacy Penobscot Community Health Center Inc 2079929200-1539	10/10/2024 1:21 PM
Details	Last Recertification Date	Update	Recertification	2/9/2023 9:59:21 AM	2/9/2024 7:48:00 AM	2/9/2024 7:48 AM
Contacts	Primary Contact	Update	Profile Change Request	McGrady, Frank R Director of Pharmacy Penobscot Community Health Center Inc 2079922000-1539	McGrady, Frank R Director of Pharmacy Penobscot Community Health Center Inc 2079929200-1539	10/10/2023 12:38 PM
Details	Last Recertification Date	Update	Recertification	2/10/2022 12:31:47 PM	2/9/2023 9:59:21 AM	2/9/2023 9:59 AM
Details	Last Recertification Date	Update	Recertification	2/10/2021 6:26:24 AM	2/10/2022 12:31:47 PM	2/10/2022 12:31 PM
Medicaid Billing	NPI: State	Update	Recertification		ME	2/10/2021 6:26 AM
Details	Last Recertification Date	Update	Recertification		2/10/2021 6:26:24 AM	2/10/2021 6:26 AM
Addresses	Billing Address	Insert	Change Request		PENOBSCOT COMMUNITY HEALTH CENTER, INC PO BOX 2100 BANGOR, ME 04401	10/26/2020 8:45 AM
Addresses	Shipping Address	Insert	Change Request		PENOBSCOT COMMUNITY HEALTH CENTER, INC 1012 UNION STREET SUITE 1 BANGOR, ME 04401	10/26/2020 8:45 AM
Details	State	Update		Approved	Active	4/1/2020 12:05 AM
Contacts	Signed By	Insert	New Registration		Dwyer, Lorelle President & CEO Penobscot Community Health Center Inc. 2079929200	2/28/2020 2:30 PM
Details	340B ID	Update	New Registration		CH01458BL	2/28/2020 2:30 PM
Dates	Participating Approval Date	Update	New Registration		2/28/2020 2:30:38 PM	2/28/2020 2:30 PM
Details	State	Update	New Registration	Pending	Approved	2/28/2020 2:30 PM
Dates	Signed By Date	Update	New Registration		1/27/2020 3:04:17 PM	2/28/2020 2:30 PM
Dates	Start Date	Update	New Registration		4/1/2020 12:00:00 AM	2/28/2020 2:30 PM
Addresses	Main Address	Insert	New Registration		1068 Union St Bangor, ME 04401-3016	1/27/2020 9:51 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1083259410	1/27/2020 9:51 AM
Contacts	Authorizing Official	Insert	New Registration		Dwyer, Lorelle President & CEO Penobscot Community Health Center Inc. 2079929200	1/27/2020 9:51 AM
Contacts	Primary Contact	Insert	New Registration		McGrady, Frank R Director of Pharmacy Penobscot Community Health Center Inc 2079922000-1539	1/27/2020 9:51 AM
Details	Last Recertification Date	Insert	New Registration			1/27/2020 9:51 AM
Details	Grant Number	Insert	New Registration		H80CS04291	1/27/2020 9:51 AM
Details	340B ID	Insert	New Registration			1/27/2020 9:51 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/27/2020 9:51 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/27/2020 9:51 AM
Details	Medicare Provider Number	Insert	New Registration			1/27/2020 9:51 AM
Details	Entity Name	Insert	New Registration		Penobscot Community Health Center	1/27/2020 9:51 AM
Details	Program Code	Insert	New Registration		CH	1/27/2020 9:51 AM
Details	Entity Subname	Insert	New Registration		Adult Wellness Center	1/27/2020 9:51 AM
Dates	Participating Approval Date	Insert	New Registration			1/27/2020 9:51 AM
Details	State	Insert	New Registration		Pending	1/27/2020 9:51 AM
Dates	Registration Date	Insert	New Registration		1/27/2020 9:51:08 AM	1/27/2020 9:51 AM
Dates	Signed By Date	Insert	New Registration			1/27/2020 9:51 AM
Dates	Start Date	Insert	New Registration			1/27/2020 9:51 AM
Terminations	Termination Comments	Insert	New Registration			1/27/2020 9:51 AM
Terminations	Termination Date	Insert	New Registration			1/27/2020 9:51 AM
Terminations	Termination Effective Date	Insert	New Registration			1/27/2020 9:51 AM
Terminations	Termination Reason	Insert	New Registration			1/27/2020 9:51 AM

340B Drug Pricing Program Database