Contract Pharmacy Details

AFFILIATED HEALTH SERVICES, INC.
DSH230165 Ascension St. John Hospital DBA Henry Ford St. John Hospital

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

AFFILIATED HEALTH SERVICES, INC.

Pharmacy Address

DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334

Pharmacy Comments

Contract Details

Approval Date

10/12/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/24/2022
Business decision by covered entity and/or pharmacy

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

340B Drug Pricing Program Database