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AFFILIATED HEALTH SERVICES, INC.
DSH230165G 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
FAMILY MEDICAL CENTER OUTPATIENT SATELLITE
Type
Disproportionate Share Hospital
340B ID
DSH230165G
Entity Address
24911 LITTLE MACK
Suite C
ST CLAIR SHORES, MI 48080
Medicare Provider Number
230165
Outpatient Facility Provider Number
Participating Start Date
4/1/2006
Last Recertification Date
8/15/2024
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
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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