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MUNSON HEALTHCARE SPECIALTY PHARMACY
CAH231300-00 PAUL OLIVER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PAUL OLIVER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231300-00
Entity Address
224 PARK AVENUE
FRANKFORT, MI 49635
Medicare Provider Number
231300
Participating Start Date
9/20/2010
Last Recertification Date
8/26/2024
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
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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