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MEDIVERA COMPOUNDING PHARMACY
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
MEDIVERA COMPOUNDING PHARMACY
Pharmacy Address
5225 CROOKS RD
TROY, MI 48098
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
1/1/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Colleen Koppenhaver, Chief Financial Officer
(989) 729-4824
Contract Pharmacy Representative
University Pharmacy
Chad Whitefield, Pharmacist in charger
(877) 531-1147
Signed By Date
10/15/2018
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