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ST JOHN VALLEY PHARMACY LLC
CAH201317-00 NORTHERN MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTHERN MAINE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201317-00
Entity Address
194 EAST MAIN STREET
FORT KENT, ME 04743
Medicare Provider Number
201317
Participating Start Date
12/6/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
ST JOHN VALLEY PHARMACY LLC
Pharmacy Address
182 MARKET ST
PO BOX 189
FORT KENT, ME 04743
Pharmacy Comments
Contract Details
Approval Date
12/6/2024
Contract Begin Date
12/6/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/29/2024
Ownership change
Contacts
Covered Entity Signing Official
Alain Bois, Chief Operating Officer
(207) 834-1411
Contract Pharmacy Representative
Bangor Drug LTC
Charles Ouellette, Owner
(207) 834-2880
Signed By Date
12/5/2024
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