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WAL-MART PHARMACY 10-2061
CAH231328-00 Ascension Borgess Allegan Hospital
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Covered Entity Details
Entity Name
Ascension Borgess Allegan Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231328-00
Entity Address
555 LINN STREET
ALLEGAN, MI 49010
Medicare Provider Number
231328
Participating Start Date
9/2/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2061
Pharmacy Address
412 CROSS OAKS MALL
PLAINWELL, MI 49080
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/9/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dorotha Hoffman, Interim Administrator
(269) 686-4162
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2020
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