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KROGER PHARMACY
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
KROGER PHARMACY
Pharmacy Address
16705 FORT ST.
SOUTHGATE, MI 48195
Pharmacy Comments
Contract Details
Approval Date
1/18/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Edward Chadwick, EVP, Finance and Admin & CFO
(313) 876-8714
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/18/2017
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