Contract Pharmacy Details

CARLETON DRUGS
DSH230053 HENRY FORD HOSPITAL

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

CARLETON DRUGS

Pharmacy Address

201 MEDICAL CENTER DRIVE
CARLETON, MI 48117

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

7/20/2015
Ownership change

Contacts

Covered Entity Signing Official

James Connelly, CFO
(313) 876-8714

Contract Pharmacy Representative

Randy Oleynik, Owner
(734) 654-6252

Signed By Date

10/15/2012