Contract Pharmacy Details

WILLIAM BEAUMONT HOSPITAL
RWI48201B Matrix Human Services

Covered Entity Details

Entity Name

Matrix Human Services

Subdivision Name

William Beaumont Hospital site

Type

Ryan White Part A

340B ID

RWI48201B

Entity Address

3601 W. Thirteen Mile Road
Royal Oak, MI 48073-6769

Grant Number

H89HA00021

Participating Start Date

1/1/2016

Last Recertification Date

2/5/2019

Entity Termination Date

1/1/2020

Pharmacy Details

Pharmacy Name

WILLIAM BEAUMONT HOSPITAL

Pharmacy Address

DBA COREWELL HEALTH SPECIALTY PHARMACY
41965 ECORSE RD
STE 100
VAN BUREN TWP, MI 48111

Pharmacy Comments

Contract Details

Approval Date

4/12/2017

Contract Begin Date

7/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/12/2019
Business decision by covered entity and/or pharmacy

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

4/12/2017

340B Drug Pricing Program Database