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BRIDGEPORT HEALTH-MART PHARMACY
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 HEALTH-MART PHARMACY
Pharmacy Address
6224 DIXIE HWY
BRIDGEPORT, MI 48722-9513
Pharmacy Comments
Contract Details
Approval Date
4/16/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SPENCE MAIDLOW, CEO
(989) 583-6400
Contract Pharmacy Representative
Mayur Patel, Registered Pharmacist in Charge/Manager
(989) 777-2900
Signed By Date
4/16/2014
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