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KROGER CO OF MICHIGAN #675
DSH230207 McLaren Oakland
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Covered Entity Details
Entity Name
McLaren Oakland
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230207
Entity Address
50 NORTH PERRY
PONTIAC, MI 48342
Medicare Provider Number
230207
Participating Start Date
1/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
KROGER CO OF MICHIGAN #675
Pharmacy Address
5111 HIGHLAND RD
WATERFORD, MI 48327
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/25/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew LeGault, CFO
(248) 338-5691
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/15/2016
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