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GREAT LAKES PHARMACY
DSH360059 METROHEALTH MEDICAL CENTER
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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
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