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WALGREEN CO.
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10404
1290 W MAIN ST
GAYLORD, MI 49735
Pharmacy Comments
Contract Details
Approval Date
7/17/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LEMON, CHIEF EXECUTIVE OFFICER
(989) 731-2215
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2016
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