340B Drug Pricing Program Database
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DSH230092X W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital (Terminated)
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Main Details
Name
W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital
Subdivision Name
Henry Ford Allegiance Addiction Recovery Center
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH230092X
Medicare Provider Number
230092
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/11/2011
Participating Start Date
4/1/2011
Participating Approval Date
3/15/2011
Last Recertification Date
8/30/2021
Termination Date
Termination Reason
10/1/2022
Business decision by the Covered Entity
Contacts
Authorizing Official
Henry Ford Allegiance Health
Jim Bongiorno, CFO
(517) 205-4899
Primary Contact
W. A. Foote Memorial Hospital dba Henry Ford Allegiance Health
Laura Ratcliff, Manager - Pharmacy Regulatory Program
(517) 205-7557
Addresses
Street Address
2424 W. Washington Avenue
Suite 200
Jackson, MI 49203
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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02/15/11 DOC RECD TO CONFIRM ELIG DSH ADJ %
03/15/2011
May 2025
May 2025
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