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WALGREEN CO.
DSH520066BK MERCY HEALTH SYSTEM CORPORATION
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Covered Entity Details
Entity Name
MERCY HEALTH SYSTEM CORPORATION
Subdivision Name
MERCY CLINIC EAST - East Pediatric Gastroenterology
Type
Disproportionate Share Hospital
340B ID
DSH520066BK
Entity Address
3524E MILWAUKEE ST
JANESVILLE, WI 53546-1626
Medicare Provider Number
520066
Outpatient Facility Provider Number
Participating Start Date
7/1/2019
Last Recertification Date
8/25/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12136
910 BROAD ST.
BELOIT, WI 53511
Pharmacy Comments
Contract Details
Approval Date
5/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/22/2022
Agreement registered in error
Contacts
Covered Entity Signing Official
John Cook, Senior VP / CFO
(608) 756-6642
Contract Pharmacy Representative
Walgreens
Tony Joe Chriscoe, 340 Client Relations Analyst
(847) 315-5806
Signed By Date
4/9/2019
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