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SHOPKO PHARMACY #2651
CAH231320-00 Trinity Health Shelby Hospital
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Covered Entity Details
Entity Name
Trinity Health Shelby Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231320-00
Entity Address
72 SOUTH STATE STREET
SHELBY, MI 49455
Medicare Provider Number
231320
Participating Start Date
8/9/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2651
Pharmacy Address
2278 N COMFORT DR
HART, MI 49420
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
JAY BRYAN, PRESIDENT
(231) 861-3030
Contract Pharmacy Representative
Shopko Pharmacy
Debi Danbury, 340B Program Manager
(920) 429-7613
Signed By Date
4/12/2018
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