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RITE AID OF MICHIGAN, INC.
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
RITE AID OF MICHIGAN, INC.
Pharmacy Address
RITE AID #2473
5280 NORTH HURON ROAD
OSCODA, MI 48750
Pharmacy Comments
Contract Details
Approval Date
4/17/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/21/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ann M. Balfour, Chief Administrative Officer
(989) 362-9301
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
4/17/2014
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