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KENNEBEC PHARMACY & HOMECARE
DSH200063 PENOBSCOT BAY MEDICAL CENTER
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Covered Entity Details
Entity Name
PENOBSCOT BAY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200063
Entity Address
6 Glen Cove Dr
Rockport, ME 04856
Medicare Provider Number
200063
Participating Start Date
4/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KENNEBEC PHARMACY & HOMECARE
Pharmacy Address
839 COMMERCIAL ST
ROCKPORT, ME 04856-4243
Pharmacy Comments
Contract Details
Approval Date
2/27/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MAURA KELLY, CFO
(207) 594-6721
Contract Pharmacy Representative
Mark Manzi, Pharmacy Manager
(207) 594-0088
Signed By Date
1/11/2013
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