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WALGREEN CO.
DSH230058 MUNSON HEALTHCARE GRAYLING HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE GRAYLING HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230058
Entity Address
1100 E Michigan Ave
GRAYLING, MI 49738
Medicare Provider Number
230058
Participating Start Date
4/1/2022
Last Recertification Date
8/21/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10406
2480 E HOUGHTON AVE
WEST BRANCH, MI 48661-1150
Pharmacy Comments
Contract Details
Approval Date
2/22/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alicia Maitland, CFO
(231) 935-7840
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/17/2022
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