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MOORE FAMILY PHARMACY HAMILTON
DSH230072 HOLLAND HOSPITAL
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Covered Entity Details
Entity Name
HOLLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230072
Entity Address
602 MICHIGAN AVENUE
HOLLAND, MI 49423-4999
Medicare Provider Number
230072
Participating Start Date
1/1/2012
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
MOORE FAMILY PHARMACY HAMILTON
Pharmacy Address
3416 M-40
HAMILTON, MI 49419
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Pawlak, President
(616) 392-5141
Contract Pharmacy Representative
Moore Family Pharmacy
Ryan Moore, President
(269) 637-3222
Signed By Date
7/12/2021
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