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WALGREEN CO.
DSH460015 LOGAN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
LOGAN REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460015
Entity Address
1400 NORTH 500 EAST
LOGAN, UT 84341
Medicare Provider Number
460015
Participating Start Date
7/1/2011
Last Recertification Date
8/22/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16481
201 S 1300 E STE 101
SALT LAKE CITY, UT 84102
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Justin Wiser, Finance Director
(435) 716-5331
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2018
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