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WAL-MART PHARMACY 10-1798
DSH230118 HURON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
HURON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230118
Entity Address
1100 SOUTH VAN DYKE
BAD AXE, MI 48413
Medicare Provider Number
230118
Participating Start Date
7/1/2016
Last Recertification Date
9/8/2020
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1798
Pharmacy Address
1121 E CARO RD
CARO, MI 48723
Pharmacy Comments
Contract Details
Approval Date
4/10/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/7/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William Castle, CEO
(989) 550-1587
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/10/2017
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