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FAMILY FARE PHARMACY #1580
DSH230059 SAINT MARY'S HEALTH CARE
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Covered Entity Details
Entity Name
SAINT MARY'S HEALTH CARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230059
Entity Address
200 JEFFERSON SE
GRAND RAPIDS, MI 49503
Medicare Provider Number
230059
Participating Start Date
12/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
FAMILY FARE PHARMACY #1580
Pharmacy Address
2900 BURLINGAME AVE. SW
WYOMING, MI 49509
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel G. Green, Vice President for Finance
(616) 685-6709
Contract Pharmacy Representative
Eddie Garcia, Director of Pharmacy
(616) 878-2975
Signed By Date
4/15/2016
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