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CVS STATE CAPITAL, L.L.C.
DSH200039 MAINEGENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MAINEGENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200039
Entity Address
35 Medical Center Parkway
Augusta, ME 04330
Medicare Provider Number
200039
Participating Start Date
7/1/2008
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
CVS PHARMACY # 17382
119 CROSSING WAY
AUGUSTA, ME 04330
Pharmacy Comments
Contract Details
Approval Date
7/1/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terrance Brann, Chief Financial Officer
(207) 623-6624
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/1/2019
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