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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10251
1410 S US HWY 27
ST JOHNS, MI 48879-2432
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
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeff Provenzano, Vice President and CFO
(989) 466-3281
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2018
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