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FAIRLANE PHARMACY SERVICES CORP
RRC230146-00 HENRY FORD HEALTH WYANDOTTE HOSPITAL
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Covered Entity Details
Entity Name
HENRY FORD HEALTH WYANDOTTE HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230146-00
Entity Address
2333 BIDDLE
WYANDOTTE, MI 48192
Medicare Provider Number
230146
Participating Start Date
7/1/2018
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAIRLANE PHARMACY SERVICES CORP
Pharmacy Address
22505 ALLEN RD
WOODHAVEN, MI 48183
Pharmacy Comments
Contract Details
Approval Date
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robin Damschroder, CFO
(313) 876-8421
Contract Pharmacy Representative
Henry Ford Health System
Daniel Kus, V.P. Pharmacy Services
(248) 723-0252
Signed By Date
7/16/2018
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