Contract Pharmacy Details

WALGREEN CO
DSH260005AD SSM ST. JOSEPH HEALTH CENTER

Covered Entity Details

Entity Name

SSM ST. JOSEPH HEALTH CENTER

Subdivision Name

SSMHI at SCCMG - Wall Street Ste 330 / Heart Institute

Type

Disproportionate Share Hospital

340B ID

DSH260005AD

Entity Address

1551 Wall Street
Suite 330
St. Charles, MO 63303

Medicare Provider Number

260005

Outpatient Facility Provider Number

260005

Participating Start Date

10/1/2015

Last Recertification Date

8/22/2019

Entity Termination Date

4/1/2020

Pharmacy Details

Pharmacy Name

WALGREEN CO

Pharmacy Address

DBA: WALGREENS #10907
1410 N BLUFF ST
FULTON, MO 65251

Pharmacy Comments

Contract Details

Approval Date

7/10/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/31/2019
Agreement registered in error

Contacts

Covered Entity Signing Official

Karen D. Rewerts, Regional VP of Financa/CFO
(314) 989-2034

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/10/2018

340B Drug Pricing Program Database