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MUNSON HEALTHCARE SPECIALTY PHARMACY
DSH230058 MUNSON HEALTHCARE GRAYLING HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE GRAYLING HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230058
Entity Address
1100 E Michigan Ave
GRAYLING, MI 49738
Medicare Provider Number
230058
Participating Start Date
4/1/2022
Last Recertification Date
8/21/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
MUNSON HEALTHCARE SPECIALTY PHARMACY
Pharmacy Address
550 MUNSON AVE UNIT 4
TRAVERSE CITY, MI 49686
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kathleen M LaRaia, Vice President
(231) 392-8410
Contract Pharmacy Representative
Munson Medical Center
Matthew Born, Specialty Pharmacy Manager
(231) 935-8675
Signed By Date
7/17/2023
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