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PREVO'S FAMILY MARKETS
SCH230097-00 MUNSON MEDICAL CENTER
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Covered Entity Details
Entity Name
MUNSON MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230097-00
Entity Address
1105 SIXTH STREET
TRAVERSE CITY, MI 49684
Medicare Provider Number
230097
Participating Start Date
4/1/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
PREVO'S FAMILY MARKETS
Pharmacy Address
DBA FAMILY FARE PHARMACY #641
4122 US HIGHWAY 31 S
TRAVERSE CITY, MI 49685
Pharmacy Comments
Contract Details
Approval Date
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark Hepler, CFO
(231) 935-6702
Contract Pharmacy Representative
Lauren Leitner, Pharmacy Manager
(231) 943-4017
Signed By Date
4/14/2017
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