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ST JOHN PHARMACY
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
ST JOHN PHARMACY
Pharmacy Address
46591 ROMEO PLANK ROAD
SUITE #125
MACOMB TOWNSHIP, MI 48044
Pharmacy Comments
05/03/2012 changed city (was MACOMB TOWNSHIP)
Contract Details
Approval Date
10/12/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
TOMASINE MARX, CHIEF FINANCIAL OFFICER
(313) 343-7676
Contract Pharmacy Representative
St John Hospital and Medical Center
Gary Blake, Director Pharmacy
(313) 343-3763
Signed By Date
10/12/2014
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