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HACKLEY PROFESSIONAL PHARMACY, INC
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
HACKLEY PROFESSIONAL PHARMACY, INC
Pharmacy Address
DBA TRINITY HEALTH PHARMACY - HACKLEY
1675 LEAHY ST
STE 111
MUSKEGON, MI 49442
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel G. Green, Vice President for Finance
(616) 685-6709
Contract Pharmacy Representative
Mercy Health Partners
Tara N. Zdybel, Amb/Comm Pharm Mgr
(231) 672-4899
Signed By Date
4/17/2017
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