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WALGREEN CO.
DSH060103 AdventHealth Avista
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Covered Entity Details
Entity Name
AdventHealth Avista
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060103
Entity Address
100 Health Park Drive
Louisville, CO 80027
Medicare Provider Number
060103
Participating Start Date
1/1/2012
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07006
191 S. MCCASLIN BLVD
SUPERIOR, CO 80027-9690
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jillyan McKinney, Chief Executive Officer
(303) 673-1280
Contract Pharmacy Representative
Centura Health
VINNY POLITO, SYSTEM DIRECTOR AMB PHARMACY
(303) 673-1014
Signed By Date
7/17/2018
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