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CENTRAL PHARMACY-PERRY LLC
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
CENTRAL PHARMACY-PERRY LLC
Pharmacy Address
150 S. MAIN ST
SUITE A
PERRY, MI 48872
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Colleen Koppenhaver, Chief Financial Officer
(989) 729-4824
Contract Pharmacy Representative
Allegan Pharmacy, LLC
Fadi Nuseibeh, Member
(313) 574-3434
Signed By Date
7/14/2020
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