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BRIOVARX OF MAINE INC
DSH340002 MISSION HOSPITALS, INC.
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Covered Entity Details
Entity Name
MISSION HOSPITALS, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340002
Entity Address
509 BILTMORE AVENUE
ASHEVILLE, NC 28801
Medicare Provider Number
340002
Participating Start Date
7/1/2004
Last Recertification Date
8/29/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul L McDowell, CFO
(828) 213-0184
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
4/17/2017
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