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CROWN SPECIALTY PHARMACY
RWI48201 Matrix Human Services
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Covered Entity Details
Entity Name
Matrix Human Services
Subdivision Name
Matrix Quality Care - Ryan White Division
Type
Ryan White Part A
340B ID
RWI48201
Entity Address
1400 Woodbridge Street
Detroit, MI 48207
Grant Number
H89HA00021
Participating Start Date
1/1/2015
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
CROWN SPECIALTY PHARMACY
Pharmacy Address
CROWN PHARMACY
24401 PLYMOUTH RD
REDFORD, MI 48239-1616
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Perkins, Vice President of Health Care Services
(248) 819-0489
Contract Pharmacy Representative
Nota Consulting Group, LLC
Fungisai Nota, 340B Program Manager
(610) 742-7763
Signed By Date
7/14/2017
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