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MAXI DRUG, INC.
DSH220011 CAMBRIDGE PUBLIC HEALTH COMMISSION
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Covered Entity Details
Entity Name
CAMBRIDGE PUBLIC HEALTH COMMISSION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220011
Entity Address
1493 Cambridge Street
CAMBRIDGE, MA 02139
Medicare Provider Number
220011
Participating Start Date
7/1/1998
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
MAXI DRUG, INC.
Pharmacy Address
RITE AID #10168
467 SALEM STREET
MEDFORD, MA 02155
Pharmacy Comments
Contract Details
Approval Date
10/2/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/17/2018
Ownership change
Contacts
Covered Entity Signing Official
ROBERT DEVEY, CFO
(781) 306-8861
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/2/2013
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