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WAL-MART PHARMACY 10-1939
DSH200024 CENTRAL MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
CENTRAL MAINE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200024
Entity Address
300 MAIN STREET
LEWISTON, ME 04240-4500
Medicare Provider Number
200024
Participating Start Date
4/1/2022
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1939
Pharmacy Address
15 TIBBETTS DRIVE
BRUNSWICK, ME 04011
Pharmacy Comments
Contract Details
Approval Date
2/24/2012
Contract Begin Date
2/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Contacts
Covered Entity Signing Official
Stephen M. Gauthier, Vice President, Contracting and Business Development
(207) 795-0111
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
2/24/2012
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