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M DRUG LLC
DSH200008 MERCY HOSPITAL
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Covered Entity Details
Entity Name
MERCY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200008
Entity Address
175 Fore River Parkway
PORTLAND, ME 04102
Medicare Provider Number
200008
Participating Start Date
4/1/2022
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
M DRUG LLC
Pharmacy Address
DBA NORTHERN LIGHT PHARMACY
70 BENNETT ST
BANGOR, ME 04401
Pharmacy Comments
Contract Details
Approval Date
1/27/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Kennedy, VP of Finance
(207) 879-3363
Contract Pharmacy Representative
M DRUG llc
Matthew Marston, Interim Director
(207) 275-3239
Signed By Date
1/18/2022
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