Covered Entity Details

CHC29011-00 PACKARD HEALTH, INC. (Active) - information as of 5/1/2025 11:46:37 PM

Main Details

Name

PACKARD HEALTH, INC.

Subdivision Name

Packard Health Carpenter

Type

HRSA-Funded Health Center

Site ID

BPS-H80-033009

340B ID

CHC29011-00

Grant Number

H80CS29011

Additional Details

Current Program Status

Active

Registration Date

1/5/2016

Participating Start Date

4/1/2016

Participating Approval Date

1/8/2016

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

Packard Health
Todd R Montrief, Controller
(734) 926-4935

Primary Contact

Packard Health
Jean Callum, COO
(734) 773-1824

Addresses

Street Address

2650 Carpenter Road
Ann Arbor, MI 48108

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
MI	1467049692,1841687589,1962879890,1851769053,1457076309	1467049692,1841687589,1962879890,1851769053,1457076309

Shipping Addresses

Shipping Address 1

Packard Health Pharmacy
2650 Carpenter Road
Ann Arbor, MI 48108

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ANN ARBOR PHARMACY LLC	2418 E STADIUM BLVD		ANN ARBOR	MI	48104	04/05/2019	07/01/2019	05/26/2020	05/26/2020
Contract Detail	APEX DRUG STORES, INC.	RITE AID #4510	2603 JACKSON AVENUE	ANN ARBOR	MI	48103	07/11/2019	10/01/2019	04/23/2025	04/23/2025
Contract Detail	APEX DRUG STORES, INC.	RITE AID #4519	2980 PACKARD STREET	ANN ARBOR	MI	48108	10/10/2023	01/01/2024	04/23/2025	04/23/2025
Contract Detail	ARBOR LAKES PHARMACY, LLC	1549 HOLMES RD		YPSILANTI	MI	48198	04/05/2019	07/01/2019		07/01/2019
Contract Detail	GENOA HEALTHCARE LLC	555 TOWNER STREET, SUITE 1120D		YPSILANTI	MI	48198	04/15/2024	07/01/2024	07/01/2024	04/15/2024
Contract Detail	GENOA HEALTHCARE LLC	110 N 4TH AVE	SUITE 1100	ANN ARBOR	MI	48104	04/15/2024	07/01/2024		07/01/2024
Contract Detail	GENOA HEALTHCARE LLC	2280 E GRAND RIVER AVE	ROOM 122	HOWELL	MI	48843	04/15/2024	07/01/2024	07/01/2024	04/15/2024
Contract Detail	KROGER CO MICHIGAN #689	3200 CARPENTER ROAD		YPSILANTI	MI	48197	07/18/2016	10/01/2016		07/18/2016
Contract Detail	KROGER CO OF MICHIGAN #520	1771 MICHIGAN AVE		YPSILANTI	MI	48198	07/09/2018	10/01/2018		10/01/2018
Contract Detail	KROGER CO OF MICHIGAN #707	2010 WHITTAKER		YPSILANTI	MI	48197	07/18/2016	10/01/2016		07/18/2016
Contract Detail	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	04/18/2016	07/01/2016		04/18/2016
Contract Detail	MEIJER INC #173	5645 JACKSON ROAD		ANN ARBOR	MI	48103	04/18/2016	07/01/2016		04/18/2016
Contract Detail	MEIJER INC #27	3825 CARPENTER ROAD		YPSILANTI	MI	48197	04/18/2016	07/01/2016		04/18/2016
Contract Detail	MEIJER INC #64	3145 ANN ARBOR/SALINE RD		ANN ARBOR	MI	48103	04/18/2016	07/01/2016		04/18/2016
Contract Detail	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	10/04/2016	01/01/2017		10/04/2016
Contract Detail	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	04/18/2016	07/01/2016		04/18/2016
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/15/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	04/15/2024	07/01/2024		07/01/2024
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	04/15/2024	07/01/2024	07/01/2024	04/15/2024
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	04/15/2024	07/01/2024	07/01/2024	04/15/2024
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4332	51341 W. HURON RIVER DRIVE	BELLEVILLE	MI	48111	07/11/2019	10/01/2019	04/23/2025	04/23/2025
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4363	753 SOUTH GROVE STREET	YPSILANTI	MI	48198	07/11/2019	10/01/2019	04/23/2025	04/23/2025
Contract Detail	SUPER-X DRUGS CORPORATION	DBA THE KROGER CO OF MICH#688	400 S. MAPLE ROAD	ANN ARBOR	MI	48103	07/18/2016	10/01/2016		07/18/2016
Contract Detail	SUPERX DRUGS CORPORATION	DBA THE KROGER CO OF MI 605	2641 PLYMOUTH ROAD	ANN ARBOR	MI	48105	07/18/2016	10/01/2016		07/18/2016
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/05/2017	10/01/2017		10/01/2017
Contract Detail	WAL-MART PHARMACY 10-1824	2515 ELLSWORTH RD		YPSILANTI	MI	48197	07/18/2016	10/01/2016	05/26/2020	05/26/2020
Contract Detail	WAL-MART PHARMACY 10-2872	10562 BELLEVILLE ROAD		VAN BUREN TOWNSHIP	MI	48111	10/12/2021	01/01/2022		01/01/2022
Contract Detail	WAL-MART PHARMACY 10-5472	7000 EAST MICHIGAN AVENUE		SALINE	MI	48176	10/08/2021	01/01/2022		01/01/2022
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/05/2017	10/01/2017		10/01/2017
Contract Detail	WALGREEN CO	DBA: WALGREENS #11156	419 E MICHIGAN AVE	YPSILANTI	MI	48198	01/18/2017	04/01/2017	11/06/2019	11/06/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11197	2355 JACKSON AVE	ANN ARBOR	MI	48103	01/18/2017	04/01/2017		01/18/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05398	2170 WASHTENAW ROAD	YPSILANTI	MI	48197	01/18/2017	04/01/2017		01/18/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05842	3255 WASHTENAW AVE	ANN ARBOR	MI	48104-4201	01/18/2017	04/01/2017		01/18/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS #15650	317 S. STATE STREET	ANN ARBOR	MI	48104-2020	01/18/2017	04/01/2017		01/18/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21156	3500 WASHTENAW AVE STE E3	ANN ARBOR	MI	48104	04/02/2018	07/01/2018		04/02/2018
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/10/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	01/18/2017	04/01/2017	10/10/2018	10/11/2018
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/04/2017	01/01/2018		10/04/2017
Contract Detail	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	10/04/2017	01/01/2018		10/04/2017
Contract Detail	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	04/10/2023	07/01/2023		07/01/2023
Contract Detail	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	10/02/2023	01/01/2024		01/01/2024
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08083	3090 CARPENTER	YPSILANTI	MI	48197	04/18/2017	07/01/2017		04/18/2017
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08006	3535 PLYMOUTH RD.,	ANN ARBOR	MI	48105	01/09/2019	04/01/2019		04/01/2019
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	CVS PHARMACY # 16629	3749 CARPENTER RD	YPSILANTI	MI	48197	01/09/2019	04/01/2019		04/01/2019
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08023	1415 E. MICHIGAN AVE	YPSILANTI	MI	48198	01/09/2019	04/01/2019		04/01/2019
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 05741	7488 VILLAGE CENTER DR.	WHITMORE LAKE	MI	48189	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 01758	5408 WHITTAKER RD.	YPSILANTI	MI	48197	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08089	935 S. MAIN ST.	CHELSEA	MI	48118	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08042	10915 BELLEVILLE RD	VAN BUREN TWP	MI	48111	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08262	39350 NINE MILE RD	NORTHVILLE	MI	48167	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 07137	5449 JACKSON RD.	ANN ARBOR	MI	48103	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	CVS PHARMACY # 16171	2000 WATERS RD	ANN ARBOR	MI	48103	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08088	2100 W. STADIUM BLVD.	ANN ARBOR	MI	48103	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA CVS/PHARMACY # 3584	209 S STATE ST	ANN ARBOR	MI	48104-2005	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08097	2228 S. MAIN	ANN ARBOR	MI	48103	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08066	22421 PONTIAC TRAIL	SOUTH LYON	MI	48178	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08165	2151 WASHTENAW	YPSILANTI	MI	48197	01/09/2019	04/01/2019		04/01/2019
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08181	15240 SOUTHFIELD	ALLEN PARK	MI	48101	01/08/2020	04/01/2020		04/01/2020
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08216	1700 SOUTH INDUSTRIAL HIGHWAY	ANN ARBOR	MI	48104	01/08/2020	04/01/2020		04/01/2020

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CHC29011-00	Active	BPS-H80-033009	PACKARD HEALTH, INC.	Packard Health Carpenter	2650 Carpenter Road	Ann Arbor	MI
CHC29011-01	Active	BPS-H80-015504	PACKARD HEALTH, INC.	Shelter Association of Washtenaw County	312 W HURON ST	ANN ARBOR	MI
CHC29011-02	Active	BPS-H80-015495	PACKARD HEALTH, INC.	Packard East	200 Arnet St	Ypsilanti	MI
CHC29011-03	Active	BPS-H80-019573	PACKARD HEALTH, INC.	Packard West	1915 Pauline Boulevard	Ann Arbor	MI

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CHC29011-00	ANN ARBOR PHARMACY LLC	2418 E STADIUM BLVD		ANN ARBOR	MI	48104	07/01/2019	05/26/2020
CHC29011-00	APEX DRUG STORES, INC.	RITE AID #4510	2603 JACKSON AVENUE	ANN ARBOR	MI	48103	10/01/2019	04/23/2025
CHC29011-00	APEX DRUG STORES, INC.	RITE AID #4519	2980 PACKARD STREET	ANN ARBOR	MI	48108	01/01/2024	04/23/2025
CHC29011-00	ARBOR LAKES PHARMACY, LLC	1549 HOLMES RD		YPSILANTI	MI	48198	07/01/2019
CHC29011-00	GENOA HEALTHCARE LLC	555 TOWNER STREET, SUITE 1120D		YPSILANTI	MI	48198	07/01/2024	07/01/2024
CHC29011-00	GENOA HEALTHCARE LLC	110 N 4TH AVE	SUITE 1100	ANN ARBOR	MI	48104	07/01/2024
CHC29011-00	GENOA HEALTHCARE LLC	2280 E GRAND RIVER AVE	ROOM 122	HOWELL	MI	48843	07/01/2024	07/01/2024
CHC29011-02	GENOA HEALTHCARE LLC	555 TOWNER STREET, SUITE 1120D		YPSILANTI	MI	48198	07/01/2024	07/01/2024
CHC29011-02	GENOA HEALTHCARE LLC	110 N 4TH AVE	SUITE 1100	ANN ARBOR	MI	48104	07/01/2024
CHC29011-02	GENOA HEALTHCARE LLC	2280 E GRAND RIVER AVE	ROOM 122	HOWELL	MI	48843	07/01/2024	07/01/2024
CHC29011-01	GENOA HEALTHCARE LLC	555 TOWNER STREET, SUITE 1120D		YPSILANTI	MI	48198	07/01/2024	07/01/2024
CHC29011-01	GENOA HEALTHCARE LLC	110 N 4TH AVE	SUITE 1100	ANN ARBOR	MI	48104	07/01/2024
CHC29011-01	GENOA HEALTHCARE LLC	2280 E GRAND RIVER AVE	ROOM 122	HOWELL	MI	48843	07/01/2024	07/01/2024
CHC29011-03	GENOA HEALTHCARE LLC	555 TOWNER STREET, SUITE 1120D		YPSILANTI	MI	48198	07/01/2024	07/01/2024
CHC29011-03	GENOA HEALTHCARE LLC	110 N 4TH AVE	SUITE 1100	ANN ARBOR	MI	48104	07/01/2024
CHC29011-03	GENOA HEALTHCARE LLC	2280 E GRAND RIVER AVE	ROOM 122	HOWELL	MI	48843	07/01/2024	07/01/2024
CHC29011-00	KROGER CO MICHIGAN #689	3200 CARPENTER ROAD		YPSILANTI	MI	48197	10/01/2016
CHC29011-00	KROGER CO OF MICHIGAN #520	1771 MICHIGAN AVE		YPSILANTI	MI	48198	10/01/2018
CHC29011-00	KROGER CO OF MICHIGAN #707	2010 WHITTAKER		YPSILANTI	MI	48197	10/01/2016
CHC29011-00	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	07/01/2016
CHC29011-00	MEIJER INC #173	5645 JACKSON ROAD		ANN ARBOR	MI	48103	07/01/2016
CHC29011-00	MEIJER INC #27	3825 CARPENTER ROAD		YPSILANTI	MI	48197	07/01/2016
CHC29011-00	MEIJER INC #64	3145 ANN ARBOR/SALINE RD		ANN ARBOR	MI	48103	07/01/2016
CHC29011-00	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	01/01/2017
CHC29011-00	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	07/01/2016
CHC29011-00	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/01/2024
CHC29011-01	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/01/2024
CHC29011-02	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/01/2024
CHC29011-03	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	07/01/2024
CHC29011-00	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2024
CHC29011-01	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2024
CHC29011-02	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2024
CHC29011-03	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/01/2024
CHC29011-00	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2024	07/01/2024
CHC29011-01	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2024	07/01/2024
CHC29011-02	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2024	07/01/2024
CHC29011-03	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/01/2024	07/01/2024
CHC29011-00	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/01/2024	07/01/2024
CHC29011-01	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/01/2024	07/01/2024
CHC29011-02	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/01/2024	07/01/2024
CHC29011-03	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/01/2024	07/01/2024
CHC29011-00	PERRY DRUG STORES, INC.	RITE AID #4332	51341 W. HURON RIVER DRIVE	BELLEVILLE	MI	48111	10/01/2019	04/23/2025
CHC29011-00	PERRY DRUG STORES, INC.	RITE AID #4363	753 SOUTH GROVE STREET	YPSILANTI	MI	48198	10/01/2019	04/23/2025
CHC29011-00	SUPER-X DRUGS CORPORATION	DBA THE KROGER CO OF MICH#688	400 S. MAPLE ROAD	ANN ARBOR	MI	48103	10/01/2016
CHC29011-00	SUPERX DRUGS CORPORATION	DBA THE KROGER CO OF MI 605	2641 PLYMOUTH ROAD	ANN ARBOR	MI	48105	10/01/2016
CHC29011-00	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	10/01/2017
CHC29011-00	WAL-MART PHARMACY 10-1824	2515 ELLSWORTH RD		YPSILANTI	MI	48197	10/01/2016	05/26/2020
CHC29011-00	WAL-MART PHARMACY 10-2872	10562 BELLEVILLE ROAD		VAN BUREN TOWNSHIP	MI	48111	01/01/2022
CHC29011-00	WAL-MART PHARMACY 10-5472	7000 EAST MICHIGAN AVENUE		SALINE	MI	48176	01/01/2022
CHC29011-00	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	10/01/2017
CHC29011-00	WALGREEN CO	DBA: WALGREENS #11156	419 E MICHIGAN AVE	YPSILANTI	MI	48198	04/01/2017	11/06/2019
CHC29011-00	WALGREEN CO.	DBA: WALGREENS #11197	2355 JACKSON AVE	ANN ARBOR	MI	48103	04/01/2017
CHC29011-00	WALGREEN CO.	DBA: WALGREENS # 05398	2170 WASHTENAW ROAD	YPSILANTI	MI	48197	04/01/2017
CHC29011-00	WALGREEN CO.	DBA: WALGREENS # 05842	3255 WASHTENAW AVE	ANN ARBOR	MI	48104-4201	04/01/2017
CHC29011-00	WALGREEN CO.	DBA WALGREENS #15650	317 S. STATE STREET	ANN ARBOR	MI	48104-2020	04/01/2017
CHC29011-00	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #21156	3500 WASHTENAW AVE STE E3	ANN ARBOR	MI	48104	07/01/2018
CHC29011-00	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	01/01/2024
CHC29011-00	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/01/2017	10/10/2018
CHC29011-00	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	01/01/2018
CHC29011-00	WALGREENS.COM, INC.	DBA: WALGREENS	2225 S. PRICE ROAD	CHANDLER	AZ	85286	01/01/2018
CHC29011-00	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023
CHC29011-00	Walmart Pharmacy 10-7611	2501 Perry Rd		Plainfield	IN	46168	01/01/2024
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08083	3090 CARPENTER	YPSILANTI	MI	48197	07/01/2017
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08006	3535 PLYMOUTH RD.,	ANN ARBOR	MI	48105	04/01/2019
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	CVS PHARMACY # 16629	3749 CARPENTER RD	YPSILANTI	MI	48197	04/01/2019
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08023	1415 E. MICHIGAN AVE	YPSILANTI	MI	48198	04/01/2019
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 05741	7488 VILLAGE CENTER DR.	WHITMORE LAKE	MI	48189	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 01758	5408 WHITTAKER RD.	YPSILANTI	MI	48197	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08089	935 S. MAIN ST.	CHELSEA	MI	48118	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08042	10915 BELLEVILLE RD	VAN BUREN TWP	MI	48111	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08262	39350 NINE MILE RD	NORTHVILLE	MI	48167	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 07137	5449 JACKSON RD.	ANN ARBOR	MI	48103	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	CVS PHARMACY # 16171	2000 WATERS RD	ANN ARBOR	MI	48103	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08088	2100 W. STADIUM BLVD.	ANN ARBOR	MI	48103	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA CVS/PHARMACY # 3584	209 S STATE ST	ANN ARBOR	MI	48104-2005	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08097	2228 S. MAIN	ANN ARBOR	MI	48103	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08066	22421 PONTIAC TRAIL	SOUTH LYON	MI	48178	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08165	2151 WASHTENAW	YPSILANTI	MI	48197	04/01/2019
CHC29011-00	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08181	15240 SOUTHFIELD	ALLEN PARK	MI	48101	04/01/2020
CHC29011-00	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08216	1700 SOUTH INDUSTRIAL HIGHWAY	ANN ARBOR	MI	48104	04/01/2020

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	2/7/2024 7:15:03 AM	2/13/2025 7:54:26 AM	2/13/2025 7:54 AM
Details	Last Recertification Date	Update	Recertification	2/6/2023 8:16:16 AM	2/7/2024 7:15:03 AM	2/7/2024 7:15 AM
Addresses	Shipping Address	Insert	Change Request		Packard Health Pharmacy 2650 Carpenter Road Ann Arbor, MI 48108	4/3/2023 10:21 AM
Addresses	Main Address	Update	Change Request	2650 Carpenter Rd Ann Arbor, MI 48108	2650 Carpenter Road Ann Arbor, MI 48108	4/3/2023 10:21 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	4/3/2023 10:21 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1457076309	4/3/2023 10:21 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	4/3/2023 10:21 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1457076309	4/3/2023 10:21 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	4/3/2023 10:21 AM
Details	Last Recertification Date	Update	Recertification	2/2/2022 8:34:00 AM	2/6/2023 8:16:16 AM	2/6/2023 8:16 AM
Contacts	Authorizing Official	Update	Profile Change Request	Montrief, Todd R Chief Financial Officer Packard Health 7349264935	Montrief, Todd R Controller Packard Health 7349264935	1/18/2023 12:38 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1467049692	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1841687589	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1962879890	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1851769053	10/4/2022 9:51 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1467049692	10/4/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1841687589	10/4/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1962879890	10/4/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1851769053	10/4/2022 9:51 AM
Medicaid Billing	NPI: State	Insert	Change Request		MI	10/4/2022 9:51 AM
Contacts	Primary Contact	Update	Group Change Request	Stanek, Jessica Compliance Director Packard Health 7349264927	Callum, Jean COO Packard Health 7347731824	9/1/2022 1:05 PM
Details	Last Recertification Date	Update	Recertification	2/3/2021 11:26:50 AM	2/2/2022 8:34:00 AM	2/2/2022 8:34 AM
Addresses	Main Address	Update	Change Request	3174 Packard St. Ann Arbor, MI 48108-1947	2650 Carpenter Rd Ann Arbor, MI 48108	12/13/2021 1:14 PM
Details	Entity Subname	Update	Change Request	Packard Main	Packard Health Carpenter	12/13/2021 1:14 PM
Contacts	Primary Contact	Update	Change Request	Stanek, Jessica Quality and Compliance Manager Packard Health 7349264927	Stanek, Jessica Compliance Director Packard Health 7349264927	9/30/2021 7:58 AM
Details	Is Authorizing Official EHB Data	Update	Change Request	False		9/30/2021 7:58 AM
Details	Last Recertification Date	Update	Recertification	2/4/2020 8:22:24 AM	2/3/2021 11:26:50 AM	2/3/2021 11:26 AM
Details	Last Recertification Date	Update	Recertification	1/30/2019 1:10:50 PM	2/4/2020 8:22:24 AM	2/4/2020 8:22 AM
Contacts	Authorizing Official	Update	AO Change Request	Jacoby, Mark CFO Packard Health, Inc. 7349711073	Montrief, Todd R Chief Financial Officer Packard Health 7349264935	2/3/2020 7:58 AM
Contacts	Primary Contact	Update	Profile Change Request	Kehoe, Jessica Quality and Compliance Coordinator Packard Health 7349264927	Stanek, Jessica Quality and Compliance Manager Packard Health 7349264927	4/4/2019 11:11 AM
Details	Last Recertification Date	Update	Recertification	2/9/2018 8:22:26 AM	1/30/2019 1:10:50 PM	1/30/2019 1:10 PM
Details	Last Recertification Date	Update	Recertification	1/25/2017 12:00:00 AM	2/9/2018 8:22:26 AM	2/9/2018 8:22 AM
Contacts	Authorizing Official	Update		Jacoby, Mark CFO 7349711073	Jacoby, Mark CFO Packard Health, Inc. 7349711073	10/4/2017 2:07 PM
Contacts	Signed By	Update		Jacoby, Mark CFO 7349711073	Jacoby, Mark CFO Packard Health, Inc. 7349711073	10/4/2017 2:07 PM
Contacts	Primary Contact	Update		Kehoe, Jessica Quality and Compliance Coordinator 7349264927	Kehoe, Jessica Quality and Compliance Coordinator Packard Health 7349264927	9/26/2017 1:24 PM
Contacts	Authorizing Official	Insert			Jacoby, Mark CFO 7349711073	8/14/2017 3:08 PM
Contacts	Signed By	Insert			Jacoby, Mark CFO 7349711073	8/14/2017 3:08 PM
Contacts	Primary Contact	Insert			Kehoe, Jessica Quality and Compliance Coordinator 7349264927	5/10/2017 10:41 AM
Addresses	Main Address	Insert			3174 Packard St. Ann Arbor, MI 48108-1947	5/10/2017 10:41 AM
Details	Last Recertification Date	Update			1/25/2017 12:00:00 AM	1/25/2017 10:00 AM
Dates	Participating Approval Date	Update			1/8/2016 12:00:00 AM	1/8/2016 5:45 PM
Details	State	Update		Pending	Active	1/8/2016 5:45 PM
Dates	Start Date	Update			4/1/2016 12:00:00 AM	1/8/2016 5:45 PM
Details	340B ID	Update		ONLINE_REG_56515	CHC29011-00	1/6/2016 12:33 PM
Details	340B ID	Update		ONLINE_REG	ONLINE_REG_56515	1/5/2016 6:36 AM
Details	Last Recertification Date	Insert				1/5/2016 6:36 AM
Details	Grant Number	Insert			H80CS29011	1/5/2016 6:36 AM
Details	340B ID	Insert			ONLINE_REG	1/5/2016 6:36 AM
Details	Is Authorizing Official EHB Data	Insert			False	1/5/2016 6:36 AM
Dates	Last Date That 340B Drugs Purchased	Insert				1/5/2016 6:36 AM
Details	Medicare Provider Number	Insert				1/5/2016 6:36 AM
Details	Entity Name	Insert			PACKARD HEALTH, INC.	1/5/2016 6:36 AM
Details	Program Code	Insert			CH	1/5/2016 6:36 AM
Details	Entity Subname	Insert			Packard Main	1/5/2016 6:36 AM
Dates	Participating Approval Date	Insert				1/5/2016 6:36 AM
Details	State	Insert			Pending	1/5/2016 6:36 AM
Dates	Registration Date	Insert			1/5/2016 12:00:00 AM	1/5/2016 6:36 AM
Dates	Signed By Date	Insert			1/5/2016 12:00:00 AM	1/5/2016 6:36 AM
Dates	Start Date	Insert				1/5/2016 6:36 AM
Terminations	Termination Comments	Insert				1/5/2016 6:36 AM
Terminations	Termination Date	Insert				1/5/2016 6:36 AM
Terminations	Termination Effective Date	Insert				1/5/2016 6:36 AM
Terminations	Termination Reason	Insert				1/5/2016 6:36 AM

340B Drug Pricing Program Database