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PDS-I MICHIGAN, INC.
FQHC638421 LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
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Covered Entity Details
Entity Name
LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS
Subdivision Name
LITTLE TRAVERSE BAY BANDS HEALTH DEPARTMENT
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638421
Entity Address
1260 Ajijaak Avenue
PETOSKEY, MI 49770
Grant Number
Participating Start Date
10/1/1999
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
PDS-I MICHIGAN, INC.
Pharmacy Address
RITE AID #4410
630 WEST MITCHELL STREET
PETOSKEY, MI 49770
Pharmacy Comments
Contract Details
Approval Date
4/5/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SHARON SIERZPUTOWSKI, HEALTH DIRECTOR
(231) 242-1610
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/5/2013
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