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RITE AID OF MICHIGAN, INC.
DSH230021 LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS
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Covered Entity Details
Entity Name
LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS
Subdivision Name
LAKELAND HOSPITAL - ST JOSEPH
Type
Disproportionate Share Hospital
340B ID
DSH230021
Entity Address
1234 NAPIER AVENUE
ST JOSEPH, MI 49085
Medicare Provider Number
230021
Participating Start Date
10/1/2004
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
RITE AID OF MICHIGAN, INC.
Pharmacy Address
RITE AID #4237
715 EAST FRONT STREET
BUCHANAN, MI 49107
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/22/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Vincent Konopacki, VP Finance & CFO
(269) 313-7188 Ext: 2693137188
Contract Pharmacy Representative
Rite Aid
Charlene Kaiser, VP, Managed Care Operations
(918) 645-6652
Signed By Date
7/12/2022
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