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PERRY DRUG STORES, INC.
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
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4366
9155 TELEGRAPH ROAD
TAYLOR, MI 48180
Pharmacy Comments
Contract Details
Approval Date
4/8/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
James Connelly, CFO
(313) 876-8714
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/8/2013
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