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APOTHECARY BY DESIGN ACQUISITION CO LLC
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
APOTHECARY BY DESIGN ACQUISITION CO LLC
Pharmacy Address
DBA:APOTHECARY BY DESIGN
141 PREBLE STREET
PORTLAND, ME 04101
Pharmacy Comments
Contract Details
Approval Date
10/9/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/8/2018
Ownership change
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Mark McAuliffe, CEO
(207) 899-0663 Ext: 1
Signed By Date
10/9/2015
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