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CVS STATE CAPITAL, L.L.C.
RRC200024-00 CENTRAL MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
CENTRAL MAINE MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC200024-00
Entity Address
300 MAIN STREET
LEWISTON, ME 04240-4500
Medicare Provider Number
200024
Participating Start Date
10/1/2017
Last Recertification Date
9/13/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
CVS PHARMACY # 16975
60 LONGVIEW DR
BANGOR, ME 04401
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Steve Littleson, Interim President & CEO
(207) 795-2947
Contract Pharmacy Representative
Central Maine Medical Center
Justin Mirick, Pharmacy Tech
(207) 795-2325
Signed By Date
10/11/2021
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