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WALGREEN CO.
SCH230133-03 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
OMH Medical Group - Lewiston
Type
Sole Community Hospital
340B ID
SCH230133-03
Entity Address
3040 Bourn Street
Lewiston, MI 49756
Medicare Provider Number
230133
Outpatient Facility Provider Number
238620
Participating Start Date
10/1/2013
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11689
2045 S I75 BUSINESS LOOP
GRAYLING, MI 49738
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LEMON, CHIEF EXECUTIVE OFFICER
(989) 731-2215
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/16/2017
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