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WALGREEN CO.
DSH230053 HENRY FORD HOSPITAL
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Covered Entity Details
Entity Name
HENRY FORD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230053
Entity Address
2799 WEST GRAND BLVD
DETROIT, MI 48202
Medicare Provider Number
230053
Participating Start Date
10/1/2002
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04585
17071 FORT STREET
RIVERVIEW, MI 48193
Pharmacy Comments
07/18/2013: Added DEA number per OPA instructions. 03/08/2013 zip update (was 48036)
Contract Details
Approval Date
4/11/2012
Contract Begin Date
4/11/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Polanski, CEO
(248) 642-1111
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
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