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WAL-MART PHARMACY 10-2102
SCH230303-00 Munson Healthcare Manistee Hospital
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Covered Entity Details
Entity Name
Munson Healthcare Manistee Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230303-00
Entity Address
1465 E. PARKDALE AVE
MANISTEE, MI 49660
Medicare Provider Number
230303
Participating Start Date
4/1/2017
Last Recertification Date
8/17/2020
Entity Termination Date
1/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2102
Pharmacy Address
4854 WEST U.S. HWY 10
LUDINGTON, MI 49431
Pharmacy Comments
Contract Details
Approval Date
4/4/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Darrell Lavender, COO
(231) 398-1508
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
4/4/2019
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