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ST JOHN PHARMACY
DSH230165D 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
INTERNAL MEDICINE CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH230165D
Entity Address
19251 MACK AVENUE
Suite 333
GROSSE POINTE WOODS, MI 48236
Medicare Provider Number
230165
Outpatient Facility Provider Number
Participating Start Date
4/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
ST JOHN PHARMACY
Pharmacy Address
27351 DEQUINDRE
MADISON HEIGHTS, MI 48071
Pharmacy Comments
Contract Details
Approval Date
12/2/2011
Contract Begin Date
12/2/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
TOMASINE MARX, CHIEF FINANCIAL OFFICER
(313) 343-7676
Contract Pharmacy Representative
Frank Ackley, Pharmacy Director
(586) 228-4591
Signed By Date
12/1/2011
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