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WAL-MART PHARMACY 10-5376
SCH230100-00 MYMICHIGAN MEDICAL CENTER TAWAS
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Covered Entity Details
Entity Name
MYMICHIGAN MEDICAL CENTER TAWAS
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230100-00
Entity Address
200 Hemlock Road/ M-55
Tawas City, MI 48763
Medicare Provider Number
230100
Participating Start Date
7/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5376
Pharmacy Address
621 EAST LAKE STREET
TAWAS CITY, MI 48763
Pharmacy Comments
Contract Details
Approval Date
4/17/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ann M. Balfour, Chief Administrative Officer
(989) 362-9301
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/17/2014
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