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WALGREEN CO.
DSH150169 COMMUNITY HOSPITAL OF INDIANA INC.
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF INDIANA INC.
Subdivision Name
Community Hospital North
Type
Disproportionate Share Hospital
340B ID
DSH150169
Entity Address
7150 CLEARVISTA DRIVE
INDIANAPOLIS, IN 46256
Medicare Provider Number
150169
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 02796
3003 KESSLER BLVD NORTH DR
INDIANAPOLIS, IN 46222
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/11/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Dee Moonesinghe, Physician Executive
(765) 437-2959
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/9/2019
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