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HOMETOWN PHARMACY #63 - AMBULATORY
SCH230097-00 MUNSON MEDICAL CENTER
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Covered Entity Details
Entity Name
MUNSON MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230097-00
Entity Address
1105 SIXTH STREET
TRAVERSE CITY, MI 49684
Medicare Provider Number
230097
Participating Start Date
4/1/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
HOMETOWN PHARMACY #63 - AMBULATORY
Pharmacy Address
1105 SIXTH ST RM 2451
TRAVERSE CITY, MI 49684
Pharmacy Comments
Contract Details
Approval Date
4/14/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kathleen M LaRaia, Vice President
(231) 392-8410
Contract Pharmacy Representative
HOMETOWN PHARMACY
Rebekah DesArmo, Vice President - Finance
(269) 427-7706
Signed By Date
4/14/2025
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