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SHAW'S PHARMACY INC
DSH230121 The Memorial Hospital d/b/a Memorial Healthcare
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Covered Entity Details
Entity Name
The Memorial Hospital d/b/a Memorial Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230121
Entity Address
826 W. King Street
Owosso, MI 48867
Medicare Provider Number
230121
Participating Start Date
7/1/2014
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
SHAW'S PHARMACY INC
Pharmacy Address
221 N SAGINAW STREET
DURAND, MI 48429
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Colleen Koppenhaver, Chief Financial Officer
(989) 729-4824
Contract Pharmacy Representative
Shaw's Pharmacy
Mark Pancheck, Owner
(989) 288-6886
Signed By Date
10/15/2018
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