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CVS STATE CAPITAL, L.L.C.
HV30726B Portland Community Health Center
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Covered Entity Details
Entity Name
Portland Community Health Center
Subdivision Name
Type
Ryan White Part C
340B ID
HV30726B
Entity Address
284 Cumberland Avenue
Portland, ME 04101
Grant Number
H76HA30726
Participating Start Date
4/1/2020
Last Recertification Date
2/15/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00806
51 MARKET STREET
MILL CREEK S/C
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2020
Agreement registered in error
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
4/15/2020
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