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RITE AID OF MICHIGAN, INC.
DSH230092 W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital
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Covered Entity Details
Entity Name
W. A. Foote Memorial Hospital dba Henry Ford Health Jackson Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230092
Entity Address
205 N. East Ave
JACKSON, MI 49201
Medicare Provider Number
230092
Participating Start Date
4/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
RITE AID OF MICHIGAN, INC.
Pharmacy Address
RITE AID #1265
2255 SOUTH JACKSON ROAD
JACKSON, MI 49201
Pharmacy Comments
Contract Details
Approval Date
10/2/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/15/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
JEANNE WICKENS, SVP OF FINANCE/CFO
(517) 841-6979
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
10/2/2013
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