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HENRY FORD PHARMACY ADVANTAGE
DSH230121 The Memorial Hospital d/b/a Memorial Healthcare
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Covered Entity Details
Entity Name
The Memorial Hospital d/b/a Memorial Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230121
Entity Address
826 W. King Street
Owosso, MI 48867
Medicare Provider Number
230121
Participating Start Date
7/1/2014
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
HENRY FORD PHARMACY ADVANTAGE
Pharmacy Address
2799 W GRAND BLVD
STE 100B
DETROIT, MI 48202-2608
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/23/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Colleen Koppenhaver, Chief Financial Officer
(989) 729-4824
Contract Pharmacy Representative
Henry Ford Health System
Caren El-Khoury, Manager-Pharmacy Operations
(313) 916-1666
Signed By Date
1/15/2020
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