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WALGREEN CO.
DSH140180 Presence Saints Mary and Elizabeth Medical Center
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Covered Entity Details
Entity Name
Presence Saints Mary and Elizabeth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140180
Entity Address
2233 WEST DIVISION STREET
CHICAGO, IL 60622
Medicare Provider Number
140180
Participating Start Date
7/1/2003
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 03948
5140 W DIVERSEY AVE
CHICAGO, IL 60639
Pharmacy Comments
Contract Details
Approval Date
4/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mike James Mulay, CFO
(312) 770-2105
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/8/2019
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