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WALGREEN CO.
DSH060003 CENTURA LONGMONT UNITED HOSPITAL
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Covered Entity Details
Entity Name
CENTURA LONGMONT UNITED HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060003
Entity Address
1950 WEST MOUNTAIN VIEW AVENUE
LONGMONT, CO 80501-3129
Medicare Provider Number
060003
Participating Start Date
7/1/2017
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 06785
835 E 17TH AVE
LONGMONT, CO 80504-2604
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
Daniel Frank, Chief Financial Officer
(303) 651-5488
Contract Pharmacy Representative
Longmont United Hospital
John D Ives, Director of Pharmacy
(303) 651-5116
Signed By Date
7/17/2018
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