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CVS PHARMACY INC
DSH200034 St. Mary's Regional Medical Center
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Covered Entity Details
Entity Name
St. Mary's Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200034
Entity Address
93 Campus Avenue
Lewiston, ME 04240-6030
Medicare Provider Number
200034
Participating Start Date
10/1/2002
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY INC
Pharmacy Address
150 INDUSTRIAL DR., WRHS #2
NORTH SMITHFIELD, RI 02896
Pharmacy Comments
Contract Details
Approval Date
10/14/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CAROLYN KASABIAN, CFO
(207) 777-8546
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
10/14/2014
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