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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
William Mayes, CEO
(989) 269-9521 Ext: 1587
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/11/2017
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