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GENOA HEALTHCARE LLC
HV30726E 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
HV30726E
Entity Address
63 Preble Street
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
GENOA HEALTHCARE LLC
Pharmacy Address
62 ELM STREET, SUITE 23, ROOM P
PORTLAND, ME 04101
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Ann Tucker, Chief Executive Officer
(207) 874-2141 Ext: 3886
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2021
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