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PIONEER FAMILY PHARMACY #104
CH050290 MIDMICHIGAN HEALTH SERVICES, INC
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Covered Entity Details
Entity Name
MIDMICHIGAN HEALTH SERVICES, INC
Subdivision Name
MIDMICHIGAN HEALTH PARK - HOUGHTON LAKE
Type
HRSA-Funded Health Center
340B ID
CH050290
Entity Address
9249 W Lake City RD
Houghton Lake, MI 48629-9602
Grant Number
H80CS00190
Participating Start Date
1/1/2004
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
PIONEER FAMILY PHARMACY #104
Pharmacy Address
412 NORTH FIFTH STREET
ROSCOMMON, MI 48653
Pharmacy Comments
Contract Details
Approval Date
12/21/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Darrell E. Milner, Executive Director
(989) 422-2104
Contract Pharmacy Representative
Robert Phetteplace, Vice President of Operations
(989) 275-5600
Signed By Date
10/31/2012
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