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WOODWARD DETROIT CVS, L.L.C.
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
WOODWARD DETROIT CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08041
414 S. MAIN ST.
BROOKLYN, MI 49230
Pharmacy Comments
Contract Details
Approval Date
10/7/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JEANNE WICKENS, SVP OF FINANCE/CFO
(517) 841-6979
Contract Pharmacy Representative
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
10/7/2013
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