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CRYSTAL FALLS PHARMACY
SCH230055-00 Marshfield Medical Center - Dickinson
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Covered Entity Details
Entity Name
Marshfield Medical Center - Dickinson
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230055-00
Entity Address
1721 S. Stephenson Avenue
Iron Mountain, MI 49801
Medicare Provider Number
230055
Participating Start Date
7/1/2017
Last Recertification Date
8/30/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
CRYSTAL FALLS PHARMACY
Pharmacy Address
1363 US HIGHWAY 2
PO BOX 7
CRYSTAL FALLS, MI 49920
Pharmacy Comments
Contract Details
Approval Date
1/5/2012
Contract Begin Date
1/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/22/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eileen Sparpana, Chief Financial Officer
(906) 776-5506
Contract Pharmacy Representative
Steve Roell, President
(906) 774-2841
Signed By Date
11/18/2011
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