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SHOPKO PHARMACY #2123
CHC26511-05 UPPER GREAT LAKES FAMILY HEALTH CENTER
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Covered Entity Details
Entity Name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Subdivision Name
Ontonagon Family Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26511-05
Entity Address
751 7th Avenue South
Ontonagon, MI 49953
Grant Number
H80CS26511
Participating Start Date
7/1/2014
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2123
Pharmacy Address
900 MEMORIAL ROAD WEST
HOUGHTON, MI 49931
Pharmacy Comments
Contract Details
Approval Date
4/15/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/28/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
Shopko
Tad Schilke, Director of Rx Merchandising & Marketing
(920) 429-7628
Signed By Date
4/15/2014
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