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CVS STATE CAPITAL, L.L.C.
CHC25680-06 PORTLAND COMMUNITY HEALTH CENTER
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Covered Entity Details
Entity Name
PORTLAND COMMUNITY HEALTH CENTER
Subdivision Name
Greater Portland Health at Portland High School
Type
HRSA-Funded Health Center
340B ID
CHC25680-06
Entity Address
284 Cumberland Ave
Portland, ME 04101-4989
Grant Number
H80CS25680
Participating Start Date
1/1/2017
Last Recertification Date
3/3/2025
Pharmacy Details
Pharmacy Name
CVS STATE CAPITAL, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00454
510 CONGRESS STREET
PORTLAND, ME 04101
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ann Tucker, Chief Executive Officer
(207) 874-2141 Ext: 3886
Contract Pharmacy Representative
CVS Health
Gina Lohr, 340B Regional Director
(401) 537-8808
Signed By Date
4/11/2018
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