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CVS STATE CAPITAL, L.L.C.
DSH200041 INLAND HOSPITAL
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Covered Entity Details
Entity Name
INLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200041
Entity Address
200 KENNEDY MEMORIAL DRIVE
WATERVILLE, ME 04901
Medicare Provider Number
200041
Participating Start Date
7/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
CVS PHARMACY # 17382
119 CROSSING WAY
AUGUSTA, ME 04330
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Frauenhofer, VICE PRESIDENT OF FINANCE
(207) 861-3013
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/17/2023
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