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WALGREEN CO.
DSH100017 HALIFAX HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
HALIFAX HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100017
Entity Address
303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114
Medicare Provider Number
100017
Participating Start Date
1/1/2009
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #21198
1348 W INTERNATIONAL SPEEDWAY BLVD STE 2
DAYTONA BEACH, FL 32114
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ERIC M. PEBURN, CFO
(386) 425-4568
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/9/2019
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