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LC FAMILY PHARMACY
DSH230081 MUNSON HEALTHCARE CADILLAC HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE CADILLAC HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230081
Entity Address
400 HOBART ST
CADILLAC, MI 49601
Medicare Provider Number
230081
Participating Start Date
4/1/2022
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
LC FAMILY PHARMACY
Pharmacy Address
57 N MOREY RD
LAKE CITY, MI 49651
Pharmacy Comments
Contract Details
Approval Date
2/23/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alicia Maitland, CFO
(231) 935-7840
Contract Pharmacy Representative
LC Family Pharmacy
Lacey Gilde, Owner
(232) 559-0005
Signed By Date
1/17/2022
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