Contract Pharmacy Details

GREAT LAKES PHARMACY
DSH360059 METROHEALTH MEDICAL CENTER

Covered Entity Details

Entity Name

METROHEALTH MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH360059

Entity Address

2500 MetroHealth Drive
CLEVELAND, OH 44109-1900

Medicare Provider Number

360059

Participating Start Date

1/1/1994

Last Recertification Date

9/5/2024

Pharmacy Details

Pharmacy Name

GREAT LAKES PHARMACY

Pharmacy Address

9500 MENTOR AVE STE 110
MENTOR, OH 44060-8712

Pharmacy Comments

Contract Details

Approval Date

1/16/2017

Contract Begin Date

4/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/10/2019
Pharmacy closed

Contacts

Covered Entity Signing Official

Michael Stern, SVP, Chief of Staff
(216) 778-5772

Contract Pharmacy Representative

Kelly Malkamaki, Pharmacy Manager
(440) 352-2500

Signed By Date

1/16/2017