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FAMILY FARE PHARMACY #647
CAH231300-00 PAUL OLIVER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PAUL OLIVER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231300-00
Entity Address
224 PARK AVENUE
FRANKFORT, MI 49635
Medicare Provider Number
231300
Participating Start Date
9/20/2010
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FAMILY FARE PHARMACY #647
Pharmacy Address
1057 US 31 SOUTH
MANISTEE, MI 49660
Pharmacy Comments
Contract Details
Approval Date
7/18/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alicia Maitland, CFO
(231) 935-7840
Contract Pharmacy Representative
Prevos Family Markets, Inc., Family Fare, LLC
Kristina Rooney, Pharmacy Contract Admin
(616) 878-2761
Signed By Date
7/18/2022
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