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HENRY FORD PHARMACY ADVANTAGE SOUTHFIELD
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
HENRY FORD PHARMACY ADVANTAGE SOUTHFIELD
Pharmacy Address
1191 SOUTH BLVD. E.
ROCHESTER HILLS, MI 48307
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TOMASINE MARX, CHIEF FINANCIAL OFFICER
(313) 343-7676
Contract Pharmacy Representative
Henry Ford Hospital
Alexander Mansour, 340B Compliance Officer
(248) 723-0020
Signed By Date
7/15/2013
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