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WAL-MART PHARMACY 10-1919
CAH201307-00 MILLINOCKET REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MILLINOCKET REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201307-00
Entity Address
200 SOMERSET STREET
MILLINOCKET, ME 04462
Medicare Provider Number
201307
Participating Start Date
7/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1919
Pharmacy Address
250 WEST BROADWAY
LINCOLN, ME 04457
Pharmacy Comments
Contract Details
Approval Date
11/15/2012
Contract Begin Date
11/15/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MARIE VIENNEAU, CEO
(207) 723-5161 Ext: 319
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
9/28/2012
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