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THE VILLAGE PHARMACY AND COMPOUNDING 4 I
RRC230227-00 MCLAREN MACOMB
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Covered Entity Details
Entity Name
MCLAREN MACOMB
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230227-00
Entity Address
1000 HARRINGTON
MT. CLEMENS, MI 48043
Medicare Provider Number
230227
Participating Start Date
12/1/2020
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
THE VILLAGE PHARMACY AND COMPOUNDING 4 I
Pharmacy Address
21510 HARRINGTON ST STE 103
CLINTON TOWNSHIP, MI 48036
Pharmacy Comments
Contract Details
Approval Date
4/18/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/19/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brian Balutanski, Regional CFO
(586) 493-3044
Contract Pharmacy Representative
Village Pharmacy Compounding
Gabe Zawaideh, Pharmacy Manager
(248) 931-5398
Signed By Date
4/18/2023
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