Contract Pharmacy Details

FAMILY FARE PHARMACY #1586
DSH230236 METROPOLITAN HOSPITAL

Covered Entity Details

Entity Name

METROPOLITAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH230236

Entity Address

5900 BYRON CENTER AVE SW
WYOMING, MI 49519

Medicare Provider Number

230236

Participating Start Date

7/1/2004

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

FAMILY FARE PHARMACY #1586

Pharmacy Address

4325 BRETON ROAD SE
GRAND RAPIDS, MI 49512

Pharmacy Comments

Contract Details

Approval Date

10/9/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/15/2021
Pharmacy closed

Contacts

Covered Entity Signing Official

MICHAEL D. FAAS, CEO
(616) 252-4788

Contract Pharmacy Representative

Eddie Garcia, Director of Pharmacy
(616) 878-2975

Signed By Date

10/9/2013