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WAL-MART PHARMACY 10-1542
DSH230080 MCLAREN CENTRAL MICHIGAN
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Covered Entity Details
Entity Name
MCLAREN CENTRAL MICHIGAN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230080
Entity Address
1221 SOUTH DRIVE
MT PLEASANT, MI 48858
Medicare Provider Number
230080
Participating Start Date
10/1/2021
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1542
Pharmacy Address
950 EDLEWEISS PARKWAY
GAYLORD, MI 49735
Pharmacy Comments
Contract Details
Approval Date
7/27/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/18/2025
Business decision by covered entity and/or pharmacy
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
7/15/2021
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