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DSH230066AJ MERCY HEALTH HACKLEY CAMPUS (Terminated)
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Main Details
Name
MERCY HEALTH HACKLEY CAMPUS
Subdivision Name
NORTHSHORE FAMILY MEDICINE
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230066AJ
Medicare Provider Number
230066
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/13/2016
Participating Start Date
7/1/2016
Participating Approval Date
5/4/2016
Last Recertification Date
8/21/2018
Termination Date
Termination Reason
1/1/2019
Site closure
Contacts
Authorizing Official
Mercy Health
Kristi Nagengast, Vice President of Finance
(231) 672-3802
Primary Contact
Mercy Health Muskegon
Scott Butler, 340B Program Coordinator
(231) 672-4229
Addresses
Street Address
1915 HOLTON RD
MUSKEGON, MI 49445-1533
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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