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WAL-MART PHARMACY 10-1919
CAH201309-00 MRH Corp. DBA Northern Light Mayo Hospital
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Covered Entity Details
Entity Name
MRH Corp. DBA Northern Light Mayo Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201309-00
Entity Address
897 WEST MAIN STREET
DOVER FOXCROFT, ME 04426-1029
Medicare Provider Number
201309
Participating Start Date
9/22/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1919
Pharmacy Address
250 WEST BROADWAY
LINCOLN, ME 04457
Pharmacy Comments
Contract Details
Approval Date
1/11/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Nancy Glidden, CFO
(207) 564-4285
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/11/2018
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