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WALGREENS SPECIALTY PHARMACY, LLC
DSH330238 NICHOLAS H. NOYES MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
NICHOLAS H. NOYES MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330238
Entity Address
111 CLARA BARTON STREET
DANSVILLE, NY 14437
Medicare Provider Number
330238
Participating Start Date
10/1/2017
Last Recertification Date
8/15/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jay Maslyn, CFO
(585) 335-4306
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/11/2019
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