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POTTERVILLE PHARMACY INC
DSH230167 MCLAREN GREATER LANSING
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Covered Entity Details
Entity Name
MCLAREN GREATER LANSING
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230167
Entity Address
2900 COLLINS RD.
LANSING, MI 48910
Medicare Provider Number
230167
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
POTTERVILLE PHARMACY INC
Pharmacy Address
121 LANSING ROAD
POTTERVILLE, MI 48876
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dale Thompson, Chief Financial Officer
(517) 975-7555
Contract Pharmacy Representative
Rottenbucher
Fadi Nuseibeh, Officer
(517) 663-6811
Signed By Date
7/14/2021
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