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WAL-MART PHARMACY 10-1856
DSH200033 EASTERN MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
EASTERN MAINE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200033
Entity Address
489 STATE STREET
BANGOR, ME 04401
Medicare Provider Number
200033
Participating Start Date
10/1/2003
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1856
Pharmacy Address
900 STILLWATER AVENUE
BANGOR, ME 04401
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Raczek, COO, CMO, Senior VP
(207) 973-7026
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/7/2014
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