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CORAM ALTERNATE SITE SERVICES, 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
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
4334 BROCKTON DRIVE SE
SUITE D
KENTWOOD, MI 49512-4118
Pharmacy Comments
Contract Details
Approval Date
4/19/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Leonard, Vice President of Finance
(517) 205-4899
Contract Pharmacy Representative
Mileva Dragisity, Branch Manager
(616) 698-0272
Signed By Date
4/19/2017
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