Covered Entity Details

RRC230146-00 HENRY FORD HEALTH WYANDOTTE HOSPITAL (Active) - information as of 5/6/2025 11:05:58 PM

Main Details

Name

HENRY FORD HEALTH WYANDOTTE HOSPITAL

Subdivision Name

Type

Rural Referral Center

Rural

Yes

340B ID

RRC230146-00

Medicare Provider Number

230146

Additional Details

Current Program Status

Active

Registration Date

4/9/2018

Participating Start Date

7/1/2018

Participating Approval Date

5/31/2018

Last Recertification Date

8/26/2024

Contacts

Authorizing Official

Henry Ford Hospital
Doug Clark, SVP - Corporate Finance
(313) 874-5446

Primary Contact

Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020

Addresses

Street Address

2333 BIDDLE
WYANDOTTE, MI 48192

Billing Address

Henry Ford
1 Ford Place
Detroit, MI 48202

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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	1892495	1992725352

Shipping Addresses

Shipping Address 1

Henry Ford
23050 West Road
Brownstown, MI 48183

Shipping Address 2

Henry Ford Central Pharmacy Service Center
1151 Holden Street, Unit 2
Detroit, MI 48202

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCESS TO CARE LLC DBA AVEVORX	3645 N BRIARWOOD LN STE D		MUNCIE	IN	47304	01/10/2025	04/01/2025		04/01/2025
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/16/2018	10/01/2018	03/12/2021	03/12/2021
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/16/2018	10/01/2018	03/12/2021	03/12/2021
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/16/2018	10/01/2018	04/26/2024	04/26/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/05/2022	04/01/2022		04/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	04/13/2021	07/01/2021		07/01/2021
Contract Detail	APEX DRUG STORES, INC.	RITE AID #4445	15411 SOUTHFIELD ROAD	ALLEN PARK	MI	48101	04/15/2020	07/01/2020	04/13/2023	04/13/2023
Contract Detail	AVEVORX, LLC	AVEVORX, LLC	3400 W WENDOVER AVE, STE F&G	GREENSBORO	NC	27407	01/10/2025	04/01/2025		04/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY LA, LLC	2731 MANHATTAN BLVD STE B17		HARVEY	LA	70058	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4900 PROSPECTUS DR STE 300		DURHAM	NC	27713	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	4740 VICTORY LN STE C	INDIANAPOLIS	IN	46203	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	145 S 79TH ST STE 70	CHANDLER	AZ	85226	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	04/11/2025	07/01/2025		04/11/2025
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	01/10/2019	04/01/2019	10/14/2019	10/21/2019
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	04/13/2021	07/01/2021		07/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/16/2020	01/01/2021		01/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/16/2020	01/01/2021		01/01/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	07/13/2021	10/01/2021		10/01/2021
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/16/2018	10/01/2018		10/01/2018
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/15/2019	07/01/2019	07/08/2019	07/10/2019
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/16/2018	10/01/2018		10/01/2018
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/16/2018	10/01/2018		10/01/2018
Contract Detail	FAIRLANE PHARMACY SERVICES CORP	22505 ALLEN RD		WOODHAVEN	MI	48183	07/16/2018	10/01/2018		10/01/2018
Contract Detail	HENRY FORD HEALTH CENTER - BROWNSTOWN PH	23050 WEST RD		BROWNSTOWN TWP	MI	48183-1472	07/16/2018	10/01/2018		10/01/2018
Contract Detail	HENRY FORD HOME INFUSION	21298 MELROSE AVENUE		SOUTHFIELD	MI	48075	10/16/2018	01/01/2019		01/01/2019
Contract Detail	HENRY FORD MEDICAL CENTER	MAIN CAMPUS PHARMACY (LOBBY)	2799 W GRAND BLVD	DETROIT	MI	48202-2608	07/16/2018	10/01/2018		10/01/2018
Contract Detail	HENRY FORD MEDICAL CENTER PHARMACY-WYAND	2333 BIDDLE AVE		WYANDOTTE	MI	48192-4668	07/16/2018	10/01/2018		10/01/2018
Contract Detail	HENRY FORD PHARMACY ADVANTAGE	2799 W GRAND BLVD	STE 100B	DETROIT	MI	48202-2608	07/16/2018	10/01/2018		10/01/2018
Contract Detail	HENRY FORD PHARMACY ADVANTAGE SOUTHFIELD	1191 SOUTH BLVD. E.		ROCHESTER HILLS	MI	48307	07/16/2018	10/01/2018		10/01/2018
Contract Detail	INFUPHARMA LLC	DBA GLOBAL VIEW PHARMACY	2013 HARDING ST	HOLLYWOOD	FL	33020	01/10/2025	04/01/2025		04/01/2025
Contract Detail	KROGER PHARMACY	16705 FORT ST.		SOUTHGATE	MI	48195	04/15/2020	07/01/2020		07/01/2020
Contract Detail	MEIJER DISTRIBUTION INC #90	2721 WALKER AVE NW		GRAND RAPIDS	MI	49544	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER INC #123	16300 FORT STREET		SOUTHGATE	MI	48195	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER INC #208	3710 DIX HIGHWAY		LINCOLN PARK	MI	48146	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER INC #233	3565 FAIRLANE BLVD		ALLEN PARK	MI	48101	07/16/2018	10/01/2018	04/12/2021	04/13/2021
Contract Detail	MEIJER INC #35	14640 PARDEE ROAD		TAYLOR	MI	48180	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER INC #68	37201 WARREN RD		WESTLAND	MI	48185	04/15/2020	07/01/2020		07/01/2020
Contract Detail	MEIJER INC #70	22600 ALLEN RD		WOODHAVEN	MI	48183	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER INC #72	9701 BELLEVILLE ROAD		BELLEVILLE	MI	48111	04/15/2020	07/01/2020		07/01/2020
Contract Detail	MEIJER PHARMACY #278	26100 VREELAND RD		FLAT ROCK	MI	48134	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER PHARMACY #464	41255 COCA COLA DR.		BELLEVILLE	MI	48111-1827	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MEIJER SPECIALTY PHARMACY	8455 HAGGERTY ROAD		BELLEVILLE	MI	48111	04/15/2020	07/01/2020		07/01/2020
Contract Detail	MEIJER STORES LIMITED PARTNERSHIP	D/B/A MEIJER PHARMACY #463	1515 PROFIT DR.	FORT WAYNE	IN	46808	07/16/2018	10/01/2018		10/01/2018
Contract Detail	MID VALLEY HEALTH SERVICES	2800 MITCHELL RD STE P-U		CERES	CA	95307	01/10/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	10/17/2019	01/01/2020	10/23/2020	11/18/2020
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	01/16/2020	04/01/2020		04/01/2020
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	01/16/2020	04/01/2020		04/01/2020
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/05/2024	04/01/2024		04/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	01/05/2024	04/01/2024		04/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	01/10/2025	04/01/2025		04/01/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/10/2019	04/01/2019		04/01/2019
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	01/16/2020	04/01/2020		04/01/2020
Contract Detail	OPTUM PHARMACY 801, INC.	23620 N 20TH DR STE 12		PHOENIX	AZ	85085-0621	10/17/2019	01/01/2020	07/13/2020	07/13/2020
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	10/18/2019	01/01/2020		01/01/2020
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	01/16/2020	04/01/2020		04/01/2020
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	01/16/2020	04/01/2020	06/06/2022	06/06/2022
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4362	28659 TELEGRAPH ROAD	FLATROCK	MI	48134	01/16/2019	04/01/2019	04/13/2023	04/13/2023
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4322	32905 FORT RD	ROCKWOOD	MI	48173-1112	01/16/2019	04/01/2019	04/13/2023	04/13/2023
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4334	19016 FORT STREET	RIVERVIEW	MI	48193	01/16/2019	04/01/2019	04/13/2023	04/13/2023
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4366	9155 TELEGRAPH ROAD	TAYLOR	MI	48180	04/15/2020	07/01/2020	04/13/2023	04/13/2023
Contract Detail	PERRY DRUG STORES, INC.	RITE AID #4335	25050 ALLEN ROAD	WOODHAVEN	MI	48183	04/15/2020	07/01/2020	01/12/2024	01/12/2024
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/16/2018	10/01/2018	10/05/2022	10/05/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	04/13/2021	07/01/2021		07/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	07/13/2021	10/01/2021		10/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	07/13/2021	10/01/2021		10/01/2021
Contract Detail	RDS DETROIT, INC.	RITE AID #4545	1998 BIDDLE AVENUE	WYANDOTTE	MI	48192	01/16/2019	04/01/2019	04/13/2023	04/13/2023
Contract Detail	RITE AID OF MICHIGAN, INC.	RITE AID #4685	4016 OAKWOOD BOULEVARD	MELVINDALE	MI	48122	01/16/2019	04/01/2019	04/12/2021	04/13/2021
Contract Detail	THE KROGER CO OF MI #693	2060 DIX AVENUE		LINCOLN PARK	MI	48146	04/15/2020	07/01/2020		07/01/2020
Contract Detail	THE KROGER CO OF MICHIGAN 458	23849 WEST ROAD		BROWNSTOWN TOWNSHIP	MI	48134	04/15/2020	07/01/2020		07/01/2020
Contract Detail	THE KROGER CO OF MICHIGAN 708	20645 GIBRALTAR RD.		BROWNSTOWN	MI	48183	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-2912	7555 TELEGRAPH ROAD		TAYLOR	MI	48180	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-3336	23800 ALLEN ROAD		WOODHAVEN	MI	48183	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-5842	14900 DIX TOLEDO		SOUTHGATE	MI	48195	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	04/15/2020	07/01/2020		07/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05168	23007 TELEGRAPH RD.	BROWNSTOWN	MI	48134	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07206	5709 S TELEGRAPH RD	DEARBORN HEIGHTS	MI	48125-2025	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #16374	4501 WOODWARD AVE STE 105	DETROIT	MI	48201	07/16/2018	10/01/2018	03/12/2021	03/12/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04585	17071 FORT STREET	RIVERVIEW	MI	48193	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06261	20030 ECORSE RD	TAYLOR	MI	48180	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05169	1700 WEST ROAD	TRENTON	MI	48183	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01265	3221 FORT ST	WYANDOTTE	MI	48192-5312	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04498	20090 GODDARD ROAD	TAYLOR	MI	48180	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04749	1765 FORT ST.	LINCOLN PARK	MI	48146	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05596	15009 TELEGRAPH ROAD	TAYLOR	MI	48180	07/13/2021	10/01/2021	03/17/2025	03/17/2025
Contract Detail	WALGREEN CO.	DBA WALGREENS #16097	22525 WICK RD.	TAYLOR	MI	48180	07/13/2021	10/01/2021	03/24/2025	03/24/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02023	1285 N MONROE ST	MONROE	MI	48162-3115	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06546	9100 TELEGRAPH RD	TAYLOR	MI	48180	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WALGREEN CO.	WALGREENS #21208	4201 SAINT ANTOINE ST STE 2M	DETROIT	MI	48201-2153	04/05/2024	07/01/2024		07/01/2024
Contract Detail	Walgreens #21423	Walgreens Central Fill #21423	6275 Winchester Blvd	Canal WInchester	OH	43110-6537	10/06/2023	01/01/2024		01/01/2024
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/16/2018	10/01/2018	03/12/2021	03/12/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/16/2018	10/01/2018	03/12/2021	03/12/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/16/2018	10/01/2018	03/12/2021	03/12/2021
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	10/06/2023	01/01/2024		01/01/2024
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08028	11125 ALLEN ROAD	SOUTHGATE	MI	48195	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08122	3647 DIX HIGHWAY	LINCOLN PARK	MI	48146	07/16/2018	10/01/2018	02/16/2022	02/18/2022
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08232	3575 WEST ROAD	TRENTON	MI	48183	07/16/2018	10/01/2018	09/22/2023	09/22/2023
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08131	2400 FORT ST.	LINCOLN PARK	MI	48146	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08072	27000 TELEGRAPH RD	FLAT ROCK	MI	48134-1657	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08114	15300 EUREKA RD.	SOUTHGATE	MI	48195	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 00211	18900 TELEGRAPH RD.	BROWNSTOWN	MI	48174	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08064	1625 KING RD.	TRENTON	MI	48183	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08029	2025 FORT STREET	WYANDOTTE	MI	48192	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08051	22000 ECORSE RD.	TAYLOR	MI	48180	07/16/2018	10/01/2018	01/26/2024	01/26/2024
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08152	22060 OUTER DR	DEARBORN	MI	48124-3932	04/13/2021	07/01/2021		07/01/2021
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08055	18340 ALLEN ROAD	MELVINDALE	MI	48122	04/13/2021	07/01/2021	01/26/2024	01/26/2024
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08042	10915 BELLEVILLE RD	VAN BUREN TWP	MI	48111	04/13/2021	07/01/2021		07/01/2021
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08125	26101 EUREKA RD.	TAYLOR	MI	48180	04/13/2021	07/01/2021	04/24/2023	04/24/2023
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	CVS PHARMACY # 16347	23555 ALLEN RD	WOODHAVEN	MI	48183	04/13/2021	07/01/2021		07/01/2021
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA: CVS/PHARMACY # 08118	131 ELM ST.	WYANDOTTE	MI	48192	04/13/2021	07/01/2021	05/12/2022	05/12/2022
Contract Detail	WOODWARD DETROIT CVS, L.L.C.	DBA CVS/PHARMACY #11245	8900 MACOMB	GROSSE ILE	MI	48138	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08181	15240 SOUTHFIELD	ALLEN PARK	MI	48101	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08160	23800 WEST RD.	BROWNSTOWN TWP	MI	48183	07/16/2018	10/01/2018		10/01/2018
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08213	13545 EUREKA ROAD	SOUTHGATE	MI	48195	07/16/2018	10/01/2018	09/01/2022	09/01/2022
Contract Detail	WOODWARD DETROIT CVS, LLC	DBA: CVS/PHARMACY # 08218	22300 GODDARD	TAYLOR	MI	48180	04/13/2021	07/01/2021	09/01/2022	09/01/2022

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC230146-01	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Cardiology	23050 West Road	Brownstown	MI	Terminated
RRC230146-02	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Family Medicine	23050 West Road, Ste 260	Brownstown	MI	Terminated
RRC230146-03	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Oncology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-04	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Orthopedics	2070 Biddle Avenue	Wyandotte	MI	Terminated
RRC230146-05	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Riverside Family Medicine	1640 Fort St, Ste D	Trenton	MI	Terminated
RRC230146-06	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Allen Park - Family Medicine	7226 Allen Road	Allen Park	MI	Terminated
RRC230146-07	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Brownstown - Women's Health	23050 West Road, Ste 210	Brownstown	MI	Terminated
RRC230146-08	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Internal Medicine	15450 Northline Rd, Ste 101	Southgate	MI	Terminated
RRC230146-09	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Northline Women's Health	15675 Northline	Southgate	MI	Terminated
RRC230146-10	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Southgate - Women's Health/ OBGYN	15356 Trenton Road	Southgate	MI	Terminated
RRC230146-11	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Anesthesiology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-12	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Bariatric Surgery	3333 Biddle Avenue, Suite C	Wyandotte	MI	Active
RRC230146-13	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - OB-GYN	3333 Biddle Avenue, Suite A	Wyandotte	MI	Active
RRC230146-14	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Maternal Fetal/ Perinatology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-15	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Cardiovascular Neurology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-16	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Neuropsychology	2333 Biddle Avenue	Wyandotte	MI	Active
RRC230146-17	Child	RRC	HENRY FORD WYANDOTTE HOSPITAL	Henry Ford Wyandotte - Rockwood Family Medicine	21969 Huron River Rd	Rockwood	MI	Terminated
RRC230146-18	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - OPERATING ROOM	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-19	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - RADIOLOGY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-20	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - EMERGENCY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-21	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - PACU/AMBULATORY SURGERY	23050 West Road	Brownstown	MI	Active
RRC230146-22	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - ANESTHESIA	23050 West Road	Brownstown	MI	Active
RRC230146-23	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - MAMMOGRAPHY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-24	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - PET SCAN	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-25	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - PATHOLOGY	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-26	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD HEALTH CENTER - BROWNSTOWN - ULTRASOUND	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-27	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - Physical Therapy	23050 West Road	Brownstown	MI	Active
RRC230146-28	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - CT Scan	23050 West Road	Brownstown	MI	Active
RRC230146-29	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Wyandotte - Physical Therapy	3323 Biddle Ave	Wyandotte	MI	Active
RRC230146-30	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Wyandotte - Occupational Therapy	3323 Biddle Ave	Wyandotte	MI	Active
RRC230146-31	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	Henry Ford Medical Center Brownstown - Bone Densitometry	23050 West Road	Brownstown	MI	Active
RRC230146-32	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - SLEEP LAB	23050 WEST RD	BROWNSTOWN TWP	MI	Active
RRC230146-33	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER WYANDOTTE - SPEECH PATHOLOGY	3323 BIDDLE AVE	WYANDOTTE	MI	Active
RRC230146-34	Child	RRC	HENRY FORD HEALTH WYANDOTTE HOSPITAL	HENRY FORD MEDICAL CENTER BROWNSTOWN - UROGYNECOLOGY	23050 WEST RD	BROWNSTOWN	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/28/2023 12:33:53 PM	8/26/2024 12:19:49 PM	8/26/2024 12:19 PM
Addresses	Shipping Address	Delete	Change Request	Henry Ford Hospital 1151 Holden, Unit 2 Detroit, MI 48202		9/13/2023 1:58 PM
Addresses	Shipping Address	Insert	Change Request		Henry Ford Central Pharmacy Service Center 1151 Holden Street, Unit 2 Detroit, MI 48202	9/13/2023 1:58 PM
Addresses	Shipping Address	Insert	Recertification		Henry Ford Hospital 1151 Holden, Unit 2 Detroit, MI 48202	8/28/2023 12:33 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 1:27:05 PM	8/28/2023 12:33:53 PM	8/28/2023 12:33 PM
Details	Last Recertification Date	Update	Recertification	9/2/2021 8:21:02 AM	9/8/2022 1:27:05 PM	9/8/2022 1:27 PM
Details	Entity Name	Update	Recertification	HENRY FORD WYANDOTTE HOSPITAL	HENRY FORD HEALTH WYANDOTTE HOSPITAL	9/8/2022 1:27 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1992725352 (IN)		9/2/2021 8:21 AM
Details	Last Recertification Date	Update	Recertification	9/7/2020 11:08:01 AM	9/2/2021 8:21:02 AM	9/2/2021 8:21 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1992725352	9/7/2020 11:08 AM
Medicaid Billing	NPI: State	Insert	Recertification		MI	9/7/2020 11:08 AM
Medicaid Billing	NPI: State	Update	Recertification		IN	9/7/2020 11:08 AM
Details	Last Recertification Date	Update	Recertification	9/9/2019 3:08:53 PM	9/7/2020 11:08:01 AM	9/7/2020 11:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	10/2/2019 7:55 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1892495	10/2/2019 7:55 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		MI	10/2/2019 7:55 AM
Details	Last Recertification Date	Update	Recertification	9/6/2018 11:02:52 AM	9/9/2019 3:08:53 PM	9/9/2019 3:08 PM
Contacts	Authorizing Official	Update	Change Request	Damschroder, Robin CFO Henry Ford Health System 3138768421	Clark, Doug SVP - Corporate Finance Henry Ford Hospital 3138745446	8/15/2019 11:25 AM
Details	Last Recertification Date	Update	Recertification		9/6/2018 11:02:52 AM	9/6/2018 11:02 AM
Contacts	Authorizing Official	Update	Change Request	POLANSKI, JOHN CEO Henry Ford Hospital 2486421111	Damschroder, Robin CFO Henry Ford Health System 3138768421	6/27/2018 8:07 AM
Details	State	Update	Change Request	Approved	Active	6/27/2018 8:07 AM
Addresses	Billing Address	Insert	Change Request		Henry Ford 1 Ford Place Detroit, MI 48202	6/25/2018 2:59 PM
Addresses	Shipping Address	Insert	Change Request		Henry Ford 23050 West Road Brownstown, MI 48183	6/19/2018 11:49 AM
Contacts	Signed By	Insert	New Registration		POLANSKI, JOHN CEO Henry Ford Hospital 2486421111	5/31/2018 9:19 AM
Details	340B ID	Update	New Registration		RRC230146-00	5/31/2018 9:19 AM
Dates	Participating Approval Date	Update	New Registration		5/31/2018 9:19:02 AM	5/31/2018 9:19 AM
Details	State	Update	New Registration	Pending	Approved	5/31/2018 9:19 AM
Dates	Signed By Date	Update	New Registration		4/9/2018 3:27:58 PM	5/31/2018 9:19 AM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	5/31/2018 9:19 AM
Addresses	Main Address	Insert	New Registration		2333 BIDDLE WYANDOTTE, MI 48192	4/9/2018 1:57 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992725352	4/9/2018 1:57 PM
Contacts	Primary Contact	Insert	New Registration		Mansour, Alexander 340B Compliance Officer Henry Ford Hospital 2487230020	4/9/2018 1:57 PM
Contacts	Authorizing Official	Insert	New Registration		POLANSKI, JOHN CEO Henry Ford Hospital 2486421111	4/9/2018 1:57 PM
Details	Last Recertification Date	Insert	New Registration			4/9/2018 1:57 PM
Details	Grant Number	Insert	New Registration			4/9/2018 1:57 PM
Details	340B ID	Insert	New Registration			4/9/2018 1:57 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/9/2018 1:57 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/9/2018 1:57 PM
Details	Medicare Provider Number	Insert	New Registration		230146	4/9/2018 1:57 PM
Details	Entity Name	Insert	New Registration		HENRY FORD WYANDOTTE HOSPITAL	4/9/2018 1:57 PM
Details	Program Code	Insert	New Registration		RRC	4/9/2018 1:57 PM
Details	Entity Subname	Insert	New Registration			4/9/2018 1:57 PM
Dates	Participating Approval Date	Insert	New Registration			4/9/2018 1:57 PM
Details	State	Insert	New Registration		Pending	4/9/2018 1:57 PM
Dates	Registration Date	Insert	New Registration		4/9/2018 1:57:52 PM	4/9/2018 1:57 PM
Dates	Signed By Date	Insert	New Registration			4/9/2018 1:57 PM
Dates	Start Date	Insert	New Registration			4/9/2018 1:57 PM
Terminations	Termination Comments	Insert	New Registration			4/9/2018 1:57 PM
Terminations	Termination Date	Insert	New Registration			4/9/2018 1:57 PM
Terminations	Termination Effective Date	Insert	New Registration			4/9/2018 1:57 PM
Terminations	Termination Reason	Insert	New Registration			4/9/2018 1:57 PM