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FAMILY FARE PHARMACY #647
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
FAMILY FARE PHARMACY #647
Pharmacy Address
1057 US 31 SOUTH
MANISTEE, MI 49660
Pharmacy Comments
Contract Details
Approval Date
4/14/2017
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
Prevos Family Markets, Inc., Family Fare, LLC
Kristina Rooney, Pharmacy Contract Admin
(616) 878-2761
Signed By Date
4/14/2017
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