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PERRY DRUG STORES, INC.
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
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4378
1341 WRIGHT AVENUE
ALMA, MI 48801
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
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
9/18/2019
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