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CVS STATE CAPITAL, L.L.C.
CAH201312-00 MAINEHEALTH WALDO HOSPITAL
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Covered Entity Details
Entity Name
MAINEHEALTH WALDO HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201312-00
Entity Address
118 NORTHPORT AVENUE
BELFAST, ME 04915
Medicare Provider Number
201312
Participating Start Date
9/9/2010
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04158
24 STONE ST., STE120
AUGUSTA, ME 04330
Pharmacy Comments
Contract Details
Approval Date
10/5/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Heather Shanklin, Chief Financial Officer
(207) 505-4131
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/5/2022
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