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HENRY FORD ALLEGIANCE PHARMACY
DSH230092 W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital
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Covered Entity Details
Entity Name
W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230092
Entity Address
205 N. East Ave
JACKSON, MI 49201
Medicare Provider Number
230092
Participating Start Date
4/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
HENRY FORD ALLEGIANCE PHARMACY
Pharmacy Address
205 N. EAST AVE
JACKSON, MI 49201
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kevin Leonard, Vice President of Finance
(517) 205-4899
Contract Pharmacy Representative
Henry Ford Allegiance Pharmacy
Scott C Dodge, Pharmacy Supervisor
(517) 205-4907
Signed By Date
10/11/2018
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