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HACKLEY PROFESSIONAL PHARMACY, INC
CAH231320-00 Trinity Health Shelby Hospital
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Covered Entity Details
Entity Name
Trinity Health Shelby Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231320-00
Entity Address
72 SOUTH STATE STREET
SHELBY, MI 49455
Medicare Provider Number
231320
Participating Start Date
8/9/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
HACKLEY PROFESSIONAL PHARMACY, INC
Pharmacy Address
DBA TRINITY HEALTH PHARMACY - NORTH MUSK
2006 HOLTON RD STE 100
MUSKEGON, MI 49445
Pharmacy Comments
Contract Details
Approval Date
5/4/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Thomas Foss, Vice President of Operations - Trinity Health Shelby Hospital
(231) 861-3029
Contract Pharmacy Representative
Trinity Health Muskegon
Tara N. Zdybel, Manager Ambulatory Pharmacy
(231) 672-4899
Signed By Date
5/4/2023
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