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WALGREEN CO.
DSH230165 Ascension St. John Hospital DBA Henry Ford St. John Hospital
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Covered Entity Details
Entity Name
Ascension St. John Hospital DBA Henry Ford St. John Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230165
Entity Address
22101 MOROSS ROAD
DETROIT, MI 48236
Medicare Provider Number
230165
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05425
13550 W 9 MILE ROAD
OAK PARK, MI 48237
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
TOMASINE MARX, CHIEF FINANCIAL OFFICER
(313) 343-7676
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2013
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