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GREAT LAKES PHARMACY
CHC30718-02 SIGNATURE HEALTH, INC.
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Covered Entity Details
Entity Name
SIGNATURE HEALTH, INC.
Subdivision Name
Signature Health, Inc. Willoughby Clinic
Type
HRSA-Funded Health Center
340B ID
CHC30718-02
Entity Address
38882 Mentor Avenue
Willoughby, OH 44094-7875
Grant Number
H80CS30718
Participating Start Date
4/1/2017
Last Recertification Date
2/11/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
GREAT LAKES PHARMACY
Pharmacy Address
9500 MENTOR AVE STE 110
MENTOR, OH 44060-8712
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Jonathan Albert Lee, CEO
(440) 953-9999 Ext: 705133
Contract Pharmacy Representative
Great Lakes Pharmacy
Michael M Malkamaki, Business Manager
(440) 352-2500
Signed By Date
1/15/2019
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