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COMMUNITY PHARMACY OF RANDOLPH
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
COMMUNITY PHARMACY OF RANDOLPH
Pharmacy Address
268 WATER ST
RANDOLPH, ME 04346-5217
Pharmacy Comments
Contract Details
Approval Date
10/25/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/11/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Community Pharmacy, LP
Amelia Arnold, Clinical Pharmacist
(207) 621-0698 Ext: 228
Signed By Date
10/25/2021
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