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PREVO'S FAMILY MARKETS
DSH230236 METROPOLITAN HOSPITAL
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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
PREVO'S FAMILY MARKETS
Pharmacy Address
DBA FAMILY FARE PHARMACY #636
5241 NORTHLAND DR. NE
GRAND RAPIDS, MI 49525
Pharmacy Comments
Contract Details
Approval Date
10/23/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHAEL D. FAAS, CEO
(616) 252-4788
Contract Pharmacy Representative
Metro Health Hospital
Peter Joseph Haverkamp, Director of Pharmacy Services
(616) 252-7216
Signed By Date
10/23/2015
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