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WALGREEN EASTERN CO., INC.
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
WALGREEN EASTERN CO., INC.
Pharmacy Address
RITE AID #04133
701 FOREST AVE
PORTLAND, ME 04103
Pharmacy Comments
Contract Details
Approval Date
2/6/2018
Contract Begin Date
2/7/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/11/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
2/6/2018
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