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WALGREEN CO.
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS SPECIALTY PHARMACY #21163
1022 WALTON WAY SPC C
AUGUSTA, GA 30901
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lee Ann Liska, Chief Executive Officer
(706) 721-6569
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2018
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