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WALGREEN CO.
DSH510029 Thomas Memorial Hospital
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Covered Entity Details
Entity Name
Thomas Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510029
Entity Address
4605 MacCorkle Avenue, SW
South Charleston, WV 25309
Medicare Provider Number
510029
Participating Start Date
7/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS # 18982
100 21ST ST.
NITRO, WV 25143-1740
Pharmacy Comments
Contract Details
Approval Date
10/8/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/25/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Brian L Ulery, Chief Operating Officer (COO)
(304) 766-3445
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/8/2018
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