Contract Pharmacy Details

PAULS PHARMACY INC
DSH230072 HOLLAND HOSPITAL

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

PAULS PHARMACY INC

Pharmacy Address

803 LINCOLN AVE
HOLLAND, MI 49423-5306

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

8/23/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Mark Pawlak, President
(616) 392-5141

Contract Pharmacy Representative

Pauls Pharmacy Inc
Jim Bussis, President
(616) 396-5233

Signed By Date

7/12/2021