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WALGREEN CO.
DSH160045 ST LUKES METHODIST HOSPITAL
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Covered Entity Details
Entity Name
ST LUKES METHODIST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160045
Entity Address
1026 A AVENUE NE
CEDAR RAPIDS, IA 52402-3026
Medicare Provider Number
160045
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA; WALGREENS #12393
5750 C AVE NE
CEDAR RAPIDS, IA 52402
Pharmacy Comments
Contract Details
Approval Date
7/5/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael G Heinrich, CFO
(319) 369-7094
Contract Pharmacy Representative
Walgreens
Jennifer Kosatka, Analyst, 340B Client Relationship
(847) 964-7209
Signed By Date
7/5/2018
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