340B Drug Pricing Program Database
WALGREEN CO.
DSH150104 WITHAM MEMORIAL HOSPITAL - information as of 4/27/2025 1:02:10 AM
Covered Entity Details
Entity Name
WITHAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150104
Entity Address
2605 N. LEBANON STREET
LEBANON, IN 46052
Medicare Provider Number
150104
Participating Start Date
5/19/2020
Last Recertification Date
9/12/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05718
10845 E. 79TH STREET
INDIANAPOLIS, IN 46236
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
George Pogas, SR VP of Finance/CFO
(765) 485-8102
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/14/2023
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