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IC PHARMACY LLC
SCH230055-00 Marshfield Medical Center - Dickinson
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Covered Entity Details
Entity Name
Marshfield Medical Center - Dickinson
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230055-00
Entity Address
1721 S. Stephenson Avenue
Iron Mountain, MI 49801
Medicare Provider Number
230055
Participating Start Date
7/1/2017
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
IC PHARMACY LLC
Pharmacy Address
AMAZON PHARMACY #004
34 35TH STREET
STE 4BSW, UNIT 28
BROOKLYN, NY 11232
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amanda Shelast, President-Marshfield Medical Center-Dickinson
(906) 774-1313
Contract Pharmacy Representative
PillPack, LLC dba PillPack by Amazon Pharmacy
Bridget O'Connell, Managing Officer
(602) 793-8552
Signed By Date
1/15/2025
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