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PDS-I MICHIGAN, INC.
SCH230303-00 Munson Healthcare Manistee Hospital
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Covered Entity Details
Entity Name
Munson Healthcare Manistee Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230303-00
Entity Address
1465 E. PARKDALE AVE
MANISTEE, MI 49660
Medicare Provider Number
230303
Participating Start Date
4/1/2017
Last Recertification Date
8/17/2020
Entity Termination Date
1/1/2021
Pharmacy Details
Pharmacy Name
PDS-I MICHIGAN, INC.
Pharmacy Address
RITE AID #4407
1243 U.S. 31 SOUTH
MANISTEE, MI 49660
Pharmacy Comments
Contract Details
Approval Date
4/7/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Donn Lemmer, CFO
(231) 398-1188
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
4/7/2017
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