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FAMILY FARE PHARMACY #1524
CAH231325-00 MyMichigan Medical Center Gladwin
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Covered Entity Details
Entity Name
MyMichigan Medical Center Gladwin
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231325-00
Entity Address
515 QUARTER STREET
GLADWIN, MI 48624
Medicare Provider Number
231325
Participating Start Date
8/31/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
FAMILY FARE PHARMACY #1524
Pharmacy Address
1204 N STATE ST
GLADWIN, MI 48624
Pharmacy Comments
Contract Details
Approval Date
10/6/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/13/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ray Stover, Regional President
(989) 246-6203
Contract Pharmacy Representative
SpartanNash
Eddie Garcia, Director of Pharmacy
(616) 878-2975
Signed By Date
10/6/2021
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