340B Drug Pricing Program Database
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DSH230066BX MERCY HEALTH HACKLEY CAMPUS (Terminated)
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Main Details
Name
MERCY HEALTH HACKLEY CAMPUS
Subdivision Name
Mercy Health Hackley Campus Pain Clinic - Pain Medicine
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH230066BX
Medicare Provider Number
230066
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/15/2020
Participating Start Date
4/1/2020
Participating Approval Date
2/12/2020
Last Recertification Date
8/21/2020
Termination Date
Termination Reason
4/1/2021
Business decision by the Covered Entity
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
1700 Clinton St.
Muskegon, MI 49442-5502
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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