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MUNSON HEALTHCARE SPECIALTY PHARMACY
RWII49684 Munson Medical Center
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Covered Entity Details
Entity Name
Munson Medical Center
Subdivision Name
Thomas Judd Care Center
Type
Ryan White Part B
340B ID
RWII49684
Entity Address
5041 N. Royal Dr.
Suite 1
Traverse City, MI 49684
Grant Number
X07HA00044
Participating Start Date
4/1/2015
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
MUNSON HEALTHCARE SPECIALTY PHARMACY
Pharmacy Address
550 MUNSON AVE UNIT 4
TRAVERSE CITY, MI 49686
Pharmacy Comments
Contract Details
Approval Date
4/5/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kathleen M LaRaia, Vice President
(231) 392-8410
Contract Pharmacy Representative
Munson Medical Center
Matthew Born, Specialty Pharmacy Manager
(231) 935-8675
Signed By Date
4/5/2024
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