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BRIOVARX OF MAINE INC
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
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
1/10/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robin Damschroder, CFO
(313) 876-8421
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/10/2019
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