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WALGREEN CO.
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
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
1/9/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LEMON, CHIEF EXECUTIVE OFFICER
(989) 731-2215
Contract Pharmacy Representative
Otsego Memorial Hospital
KAY HANNA DELUCA, DIRECTOR, PHARMACY
(989) 731-2138
Signed By Date
1/9/2018
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