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MEIJER STORES LIMITED PARTNERSHIP
DSH230208 SPARROW CARSON HOSPITAL
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Covered Entity Details
Entity Name
SPARROW CARSON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230208
Entity Address
406 EAST ELM STREET
CARSON CITY, MI 48811
Medicare Provider Number
230208
Participating Start Date
4/1/2008
Last Recertification Date
8/22/2018
Entity Termination Date
1/1/2020
Pharmacy Details
Pharmacy Name
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
9/18/2019
Contract Begin Date
9/13/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Brisboe, Chief Financial Officer
(616) 523-1702
Contract Pharmacy Representative
Meijer
Jeff Romano, Hospital Programs
(616) 791-3171
Signed By Date
9/18/2019
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