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PERRY DRUG STORES, 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
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4424
1089 NORTH WISNER STREET
JACKSON, MI 49202
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
3/23/2022
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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