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WAL-MART PHARMACY 10-1542
RRC230080-00 McLaren Central Michigan
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Covered Entity Details
Entity Name
McLaren Central Michigan
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230080-00
Entity Address
1221 South Drive
Mount Pleasant, MI 48858
Medicare Provider Number
230080
Participating Start Date
10/1/2012
Last Recertification Date
9/3/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1542
Pharmacy Address
950 EDLEWEISS PARKWAY
GAYLORD, MI 49735
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
6/4/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tara Soules, Chief Financial Officer
(989) 772-6818
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2021
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