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MUNSON HEALTHCARE SPECIALTY PHARMACY
DSH230081 MUNSON HEALTHCARE CADILLAC HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE CADILLAC HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230081
Entity Address
400 HOBART ST
CADILLAC, MI 49601
Medicare Provider Number
230081
Participating Start Date
4/1/2022
Last Recertification Date
8/20/2024
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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