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WEST GRANGE PHARMACY LLC
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
WEST GRANGE PHARMACY LLC
Pharmacy Address
3390 WEST RD
TRENTON, MI 48183-2323
Pharmacy Comments
Contract Details
Approval Date
12/12/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Connelly, CFO
(313) 876-8714
Contract Pharmacy Representative
Richard Grossman, Owner
(734) 676-6622
Signed By Date
10/15/2012
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