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PERRY DRUG STORES, INC.
CAH231325-00 MyMichigan Medical Center Gladwin
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Covered Entity Details
Entity Name
MyMichigan Medical Center Gladwin
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231325-00
Entity Address
515 QUARTER STREET
GLADWIN, MI 48624
Medicare Provider Number
231325
Participating Start Date
8/31/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4488
120 EAST CEDAR AVE
GLADWIN, MI 48624
Pharmacy Comments
Contract Details
Approval Date
4/5/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ray Stover, Regional President
(989) 246-6203
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/5/2013
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