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RITE AID OF MICHIGAN, INC.
DSH230053 HENRY FORD HOSPITAL
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Covered Entity Details
Entity Name
HENRY FORD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230053
Entity Address
2799 WEST GRAND BLVD
DETROIT, MI 48202
Medicare Provider Number
230053
Participating Start Date
10/1/2002
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
RITE AID OF MICHIGAN, INC.
Pharmacy Address
RITE AID #4595
4612 WOODWARD AVENUE
DETROIT, MI 48201
Pharmacy Comments
Contract Details
Approval Date
10/21/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President, Managed Care
(717) 975-5968
Signed By Date
10/21/2019
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