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PERRY DRUG STORES, INC.
RRC230208-00 Sparrow Carson Hospital
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Covered Entity Details
Entity Name
Sparrow Carson Hospital
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230208-00
Entity Address
406 EAST ELM STREET
CARSON CITY, MI 48811
Medicare Provider Number
230208
Participating Start Date
10/1/2019
Last Recertification Date
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4378
1341 WRIGHT AVENUE
ALMA, MI 48801
Pharmacy Comments
Contract Details
Approval Date
9/13/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Brisboe, Chief Financial Officer
(616) 523-1702
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
9/13/2019
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