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WOODWARD DETROIT CVS, L.L.C.
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
WOODWARD DETROIT CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01748
57090 TEN MILE ROAD
SOUTH LYON, MI 48178
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Colleen Koppenhaver, Chief Financial Officer
(989) 729-4824
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2021
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