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CVS STATE CAPITAL, L.L.C.
CHC25680-05 PORTLAND COMMUNITY HEALTH CENTER
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Covered Entity Details
Entity Name
PORTLAND COMMUNITY HEALTH CENTER
Subdivision Name
Greater Portland Health at Casco Bay High School
Type
HRSA-Funded Health Center
340B ID
CHC25680-05
Entity Address
196 ALLEN AVE
PORTLAND, ME 04103-3711
Grant Number
H80CS25680
Participating Start Date
1/1/2017
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00374
449 FOREST AVENUE
PORTLAND, ME 04101
Pharmacy Comments
Contract Details
Approval Date
10/14/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ann Tucker, Chief Executive Officer
(207) 874-2141 Ext: 3886
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/14/2018
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