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KROGER CO OF MI #649
DSH230207 McLaren Oakland
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Covered Entity Details
Entity Name
McLaren Oakland
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230207
Entity Address
50 NORTH PERRY
PONTIAC, MI 48342
Medicare Provider Number
230207
Participating Start Date
1/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER CO OF MI #649
Pharmacy Address
3097 S BALDWIN RD
ORION, MI 48359
Pharmacy Comments
Contract Details
Approval Date
4/18/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/22/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lynn Marcotte, CFO
(248) 338-5691
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/18/2019
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