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PERRY DRUG STORES, INC.
DSH230072 HOLLAND HOSPITAL
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Covered Entity Details
Entity Name
HOLLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230072
Entity Address
602 MICHIGAN AVENUE
HOLLAND, MI 49423-4999
Medicare Provider Number
230072
Participating Start Date
1/1/2012
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
PERRY DRUG STORES, INC.
Pharmacy Address
RITE AID #4393
973 WASHINGTON AVE
HOLLAND, MI 49423
Pharmacy Comments
Contract Details
Approval Date
2/20/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Pawlak, President
(616) 392-5141
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
1/7/2013
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