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CYSTIC FIBROSIS SERVICES, LLC
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
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
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/17/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Darrell Lavender, COO
(231) 398-1508
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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