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FAMILY FARE PHARMACY 114
SCH230081-00 Munson Healthcare Cadillac Hospital
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Covered Entity Details
Entity Name
Munson Healthcare Cadillac Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230081-00
Entity Address
400 Hobart St
Cadillac, MI 49601
Medicare Provider Number
230081
Participating Start Date
7/1/2012
Last Recertification Date
8/19/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
FAMILY FARE PHARMACY 114
Pharmacy Address
1550 GEZON PKWY SW STE E101
WYOMING, MI 49509
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Mark Hepler, CFO
(231) 935-6702
Contract Pharmacy Representative
Prevos Family Markets, Inc., Family Fare, LLC
Kristina Rooney, Pharmacy Contract Admin
(616) 878-2761
Signed By Date
1/14/2019
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