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WAL-MART PHARMACY 10-2358
DSH230036 MyMichigan Medical Center Alpena
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Covered Entity Details
Entity Name
MyMichigan Medical Center Alpena
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230036
Entity Address
1501 W. CHISHOLM
ALPENA, MI 49707
Medicare Provider Number
230036
Participating Start Date
7/1/2019
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2358
Pharmacy Address
1180 M-32 WEST
ALPENA, MI 49707
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/24/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chuck Sherwin, President
(989) 794-7625
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/11/2021
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