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AFFILIATED HEALTH SERVICES, INC.
DSH230165F ST JOHN HOSPITAL & MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOHN HOSPITAL & MEDICAL CENTER
Subdivision Name
OUTPATIENT SATELLITE
Type
Disproportionate Share Hospital
340B ID
DSH230165F
Entity Address
20952 E TWELVE MILE ROAD
ST CLAIR SHORES, MI 48081
Medicare Provider Number
230165
Outpatient Facility Provider Number
Participating Start Date
4/1/2006
Last Recertification Date
8/31/2015
Entity Termination Date
7/1/2016
Pharmacy Details
Pharmacy Name
AFFILIATED HEALTH SERVICES, INC.
Pharmacy Address
DBA ASCENSION RX 1301
22250 PROVIDENCE DR
SOUTHFIELD, MI 48075-4825
Pharmacy Comments
Contract Details
Approval Date
11/21/2006
Contract Begin Date
11/21/2006
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/17/2006
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