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WALGREEN CO.
DSH250167 METHODIST H/C OLIVE BRANCH HOSPT
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Covered Entity Details
Entity Name
METHODIST H/C OLIVE BRANCH HOSPT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250167
Entity Address
4250 BETHEL ROAD
OLIVE BRANCH, MS 38654
Medicare Provider Number
250167
Participating Start Date
4/1/2019
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07130
6958 GOODMAN RD
OLIVE BRANCH, MS 38654
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chuck Lane, SVP/Associate CFO
(901) 516-0549
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2019
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