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VANDERBILT HEALTH PHARMACY GROUP
DSH200009 MAINEHEALTH MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
MAINEHEALTH MAINE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200009
Entity Address
22 BRAMHALL STREET
PORTLAND, ME 04102
Medicare Provider Number
200009
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
VANDERBILT HEALTH PHARMACY GROUP
Pharmacy Address
718 MELROSE AVE
NASHVILLE, TN 37211-3721
Pharmacy Comments
Contract Details
Approval Date
4/16/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Vanderbilt Health Pharmacy Group
James R Manfred, Executive Director, VHPG
(615) 322-4775
Signed By Date
4/16/2019
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