Contract Pharmacy Details

WALGREEN CO.
DSH060103 AdventHealth Avista

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 #12683
2870 28TH ST
BOULDER, CO 80301

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

340B Drug Pricing Program Database