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WAL-MART PHARMACY 10-1719
DSH230059 SAINT MARY'S HEALTH CARE
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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
WAL-MART PHARMACY 10-1719
Pharmacy Address
21400 PERRY ST
BIG RAPIDS, MI 49307
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
11/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel G. Green, Vice President for Finance
(616) 685-6709
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/16/2018
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