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PDS-I MICHIGAN, INC.
SCH230239-00 MyMichigan Medical Center Sault
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Covered Entity Details
Entity Name
MyMichigan Medical Center Sault
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230239-00
Entity Address
500 OSBORN BOULEVARD
SAULT STE. MARIE, MI 49783
Medicare Provider Number
230239
Participating Start Date
9/1/2010
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
PDS-I MICHIGAN, INC.
Pharmacy Address
RITE AID #4579
1025 ASHMUN STREET
SAULT STE MARIE, MI 49783
Pharmacy Comments
Contract Details
Approval Date
10/2/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/16/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
DAVID JAHN, PRESIDENT & CHIEF EXECUTIVE OFFICER
(906) 635-4650
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/2/2014
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