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WALGREEN CO.
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.
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Covered Entity Details
Entity Name
GOOD SAMARITAN REGIONAL HEALTH CTR.
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
10/1/2015
Last Recertification Date
9/14/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15311
115 N EUCLID AVE STE A
SAINT LOUIS, MO 63108
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
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kerry Swanson, Regional President
(618) 436-6500
Contract Pharmacy Representative
SSM Health
Jeffrey Peine, Finance Director
(314) 989-3532
Signed By Date
4/8/2019
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