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CVS STATE CAPITAL, L.L.C.
CHC25680-14 Portland Community Health Center
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Covered Entity Details
Entity Name
Portland Community Health Center
Subdivision Name
Greater Portland Health at Sagamore Village
Type
HRSA-Funded Health Center
340B ID
CHC25680-14
Entity Address
68 Popham St
Portland, ME 04102-1151
Grant Number
H80CS25680
Participating Start Date
10/1/2021
Last Recertification Date
2/23/2024
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00805
335 OCEAN HOUSE ROAD
CAPE ELIZABETH, ME 04107
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
10/1/2024
Covered Entity Terminated
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
10/15/2021
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