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PDS-I MICHIGAN, INC.
CAH231322-00 MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE CHARLEVOIX HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231322-00
Entity Address
14700 LAKE SHORE DRIVE
CHARLEVOIX, MI 49720-1931
Medicare Provider Number
231322
Participating Start Date
10/1/2012
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
PDS-I MICHIGAN, INC.
Pharmacy Address
RITE AID #4410
630 WEST MITCHELL STREET
PETOSKEY, MI 49770
Pharmacy Comments
Contract Details
Approval Date
4/6/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Lyn A. Jenks, CEO
(231) 547-8500
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
4/6/2017
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