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MEIJER STORES LIMITED PARTNERSHIP
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
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
10/9/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LEMON, CHIEF EXECUTIVE OFFICER
(989) 731-2215
Contract Pharmacy Representative
Meijer
Jeff Romano, Hospital Programs
(616) 791-3171
Signed By Date
10/9/2016
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