Contract Pharmacy Details

RITE AID OF MICHIGAN, INC.
DSH230059 SAINT MARY'S HEALTH CARE

Covered Entity Details

Entity Name

SAINT MARY'S HEALTH CARE

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH230059

Entity Address

200 JEFFERSON SE
GRAND RAPIDS, MI 49503

Medicare Provider Number

230059

Participating Start Date

12/1/2005

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

RITE AID OF MICHIGAN, INC.

Pharmacy Address

RITE AID #1524
924 WEST MAIN STREET
FREMONT, MI 49412

Pharmacy Comments

Contract Details

Approval Date

4/16/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/26/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

Daniel G. Green, Vice President for Finance
(616) 685-6709

Contract Pharmacy Representative

Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968

Signed By Date

4/16/2018

340B Drug Pricing Program Database