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WALGREEN CO.
DSH100173 AdventHealth TAMPA
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Covered Entity Details
Entity Name
AdventHealth TAMPA
Subdivision Name
University Community dba Florida Hospital Tampa
Type
Disproportionate Share Hospital
340B ID
DSH100173
Entity Address
3100 East FLETCHER Avenue
TAMPA, FL 33613
Medicare Provider Number
100173
Participating Start Date
1/1/2017
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09300
3890 VAN DYKE RD
LUTZ, FL 33548
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/11/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William Heinrich, Chief Financial Officer
(813) 615-7853
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2019
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