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BRIDGEPORT PHARMACY INC
DSH230070 COVENANT MEDICAL CENTER
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Covered Entity Details
Entity Name
COVENANT MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230070
Entity Address
1447 N HARRISON STREET
SAGINAW, MI 48602
Medicare Provider Number
230070
Participating Start Date
4/1/2004
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
BRIDGEPORT PHARMACY INC
Pharmacy Address
6224 DIXIE HIGHWAY
BRIDGEPORT, MI 48722
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/2/2016
Ownership change
Contacts
Covered Entity Signing Official
SPENCE MAIDLOW, CEO
(989) 583-6400
Contract Pharmacy Representative
Raymond Boettcher, Registered Pharmacist in Charge/Owner
(989) 777-2900
Signed By Date
7/15/2013
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