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WALGREEN CO
DSH260005AF SSM HEALTH ST. JOSEPH HOSPITAL- SC
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Covered Entity Details
Entity Name
SSM HEALTH ST. JOSEPH HOSPITAL- SC
Subdivision Name
SCCMG Wall Street Family Medicine & Internal Medicine
Type
Disproportionate Share Hospital
340B ID
DSH260005AF
Entity Address
711 Veterans Memorial Parkway
Suite 300
St. Charles, MO 63303
Medicare Provider Number
260005
Outpatient Facility Provider Number
260005
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2024
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
7/11/2018
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
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