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RITE AID OF MICHIGAN, INC.
DSH230030 MyMichigan Medical Center Alma
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Covered Entity Details
Entity Name
MyMichigan Medical Center Alma
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230030
Entity Address
300 EAST WARWICK DRIVE
ALMA, MI 48801
Medicare Provider Number
230030
Participating Start Date
4/1/2018
Last Recertification Date
8/25/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
RITE AID OF MICHIGAN, INC.
Pharmacy Address
RITE AID #1528
10767 E CARSON CITY ROAD
CARSON CITY, MI 48811
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeff Provenzano, Vice President and CFO
(989) 466-3281
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
1/12/2018
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