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MAXI DRUG, INC.
DSH220163 UMASS MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
UMASS MEMORIAL MEDICAL CENTER
Subdivision Name
UNIVERSITY CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH220163
Entity Address
55 LAKE AVENUE NORTH
WORCESTER, MA 01655
Medicare Provider Number
220163
Participating Start Date
10/1/2003
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
MAXI DRUG, INC.
Pharmacy Address
RITE AID #10090
455 MAIN STREET
SOUTHBRIDGE, MA 01550
Pharmacy Comments
Contract Details
Approval Date
10/13/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/30/2018
Ownership change
Contacts
Covered Entity Signing Official
Alice Shakman, Vice President Operations
(774) 443-0540
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/13/2015
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