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CVS STATE CAPITAL, L.L.C.
DSH200009 MAINEHEALTH MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
MAINEHEALTH MAINE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200009
Entity Address
22 BRAMHALL STREET
PORTLAND, ME 04102
Medicare Provider Number
200009
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00374
449 FOREST AVENUE
PORTLAND, ME 04101
Pharmacy Comments
Contract Details
Approval Date
7/31/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Jeffrey Mattiucci, Director, Payer Relations
(401) 770-2727
Signed By Date
7/31/2014
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