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MEIJER STORES LIMITED PARTNERSHIP
RRC230227-00 MCLAREN MACOMB
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Covered Entity Details
Entity Name
MCLAREN MACOMB
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230227-00
Entity Address
1000 HARRINGTON
MT. CLEMENS, MI 48043
Medicare Provider Number
230227
Participating Start Date
12/1/2020
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
1/12/2021
Contract Begin Date
1/22/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Balutanski, Regional CFO
(586) 493-3044
Contract Pharmacy Representative
Meijer
Katy Diaz, Pharmacy Business Associate
(616) 791-3127
Signed By Date
1/12/2021
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