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SHOPKO PHARMACY #2650
CAH231315-00 ASCENSION BORGESS-LEE HOSPITAL
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Covered Entity Details
Entity Name
ASCENSION BORGESS-LEE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231315-00
Entity Address
420 WEST HIGH STREET
DOWAGIAC, MI 49047
Medicare Provider Number
231315
Participating Start Date
9/30/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2650
Pharmacy Address
56419 POKAGON ST
DOWAGIAC, MI 49047
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/29/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
John Ryder, COO
(269) 783-3082
Contract Pharmacy Representative
ShopKo
Lorie Neumann, Contracting & Compliance
(920) 429-4726
Signed By Date
7/17/2017
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