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BRIOVARX OF MAINE INC
DSH230046 UNIVERSITY OF MICHIGAN HOSPITALS AND HEALTH CENTERS
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Covered Entity Details
Entity Name
UNIVERSITY OF MICHIGAN HOSPITALS AND HEALTH CENTERS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230046
Entity Address
1500 EAST MEDICAL CENTER DRIVE
ANN ARBOR, MI 48109
Medicare Provider Number
230046
Participating Start Date
1/1/2004
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
BRIOVARX OF MAINE INC
Pharmacy Address
DBA BRIOVARX
53 DARLING AVE
SOUTH PORTLAND, ME 04106
Pharmacy Comments
Contract Details
Approval Date
7/10/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Jeffrey S. Desmond, Chief Medical Officer
(734) 936-5814
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
7/10/2017
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