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HANNAFORD BROS. CO., LLC
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
HANNAFORD BROS. CO., LLC
Pharmacy Address
DBA HANNAFORD SUPERMARKET & PHARMACY #83
1603 MAIN ST
OXFORD, ME 04270
Pharmacy Comments
Contract Details
Approval Date
7/16/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Hannaford
Mike Fish, Pharmacy District Manager
(518) 428-2712
Signed By Date
7/16/2020
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