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WALGREEN CO.
DSH340014 Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center
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Covered Entity Details
Entity Name
Forsyth Memorial Hospital, Inc d/b/a Novant Health Forsyth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340014
Entity Address
3333 SILAS CREEK PARKWAY
WINSTON-SALEM, NC 27103-3013
Medicare Provider Number
340014
Participating Start Date
7/1/2007
Last Recertification Date
9/6/2019
Entity Termination Date
7/7/2020
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #10090
12311 N. NC HIGHWAY 150
WINSTON SALEM, NC 27127
Pharmacy Comments
Contract Details
Approval Date
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/7/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Cedric A Terrell, SVP Pharmacy Services
(704) 384-0611
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/11/2019
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