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GENOA HEALTHCARE LLC
RRC230019-00 ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL
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Covered Entity Details
Entity Name
ASCENSION PROVIDENCE HOSPITAL DBA HENRY FORD HEALTH PROVIDENCE SOUTHFIELD HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230019-00
Entity Address
16001 WEST NINE MILE ROAD
SOUTHFIELD, MI 48075
Medicare Provider Number
230019
Participating Start Date
4/1/2023
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
2280 E GRAND RIVER AVE
ROOM 122
HOWELL, MI 48843
Pharmacy Comments
Contract Details
Approval Date
10/22/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/22/2024
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