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WALMART PHARMACY #10-4439
CAH231315-00 ASCENSION BORGESS-LEE HOSPITAL
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Covered Entity Details
Entity Name
ASCENSION BORGESS-LEE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231315-00
Entity Address
420 WEST HIGH STREET
DOWAGIAC, MI 49047
Medicare Provider Number
231315
Participating Start Date
9/30/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY #10-4439
Pharmacy Address
1013 SOUTH KALAMAZOO STREET
PAW PAW, MI 49079
Pharmacy Comments
Contract Details
Approval Date
10/12/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/21/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Ryder, COO
(269) 783-3082
Contract Pharmacy Representative
Wal-Mart
Jodi Prohofsky, Sr. Director, Payer Relations
(254) 301-6601
Signed By Date
10/12/2017
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