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WAL-MART PHARMACY 10-1836
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
WAL-MART PHARMACY 10-1836
Pharmacy Address
1601 EAST U.S. 223
ADRIAN, MI 49221
Pharmacy Comments
Contract Details
Approval Date
1/14/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JEANNE WICKENS, SVP OF FINANCE/CFO
(517) 841-6979
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/14/2015
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