Contract Pharmacy Details

NORTHGATE PHARMACY
DSH230118 HURON MEMORIAL HOSPITAL

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

NORTHGATE PHARMACY

Pharmacy Address

721N. VAN DYKE
BAD AXE, MI 48413

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

12/9/2019
Pharmacy closed

Contacts

Covered Entity Signing Official

William Castle, CEO
(989) 550-1587

Contract Pharmacy Representative

Jonathan Volk, Owner
(989) 269-8061

Signed By Date

4/10/2017