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CADILLAC FAMILY PHARMACY, LLC
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
CADILLAC FAMILY PHARMACY, LLC
Pharmacy Address
108 N MITCHELL ST
CADILLAC, MI 49601-2713
Pharmacy Comments
Contract Details
Approval Date
2/23/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alicia Maitland, CFO
(231) 935-7840
Contract Pharmacy Representative
Cadillac Family Pharmacy
Lisa Lundahl, Member
(231) 775-8099
Signed By Date
1/18/2022
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