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MUNSON HEALTHCARE SPECIALTY PHARMACY
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
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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