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WALGREEN CO.
DSH210040 NORTHWEST HOSPITAL CENTER, INC.
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Covered Entity Details
Entity Name
NORTHWEST HOSPITAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210040
Entity Address
5401 OLD COURT ROAD
RANDALLSTOWN, MD 21133
Medicare Provider Number
210040
Participating Start Date
10/1/2015
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS #17587
6838 LOCH RAVEN BLVD
BALTIMORE, MD 21286
Pharmacy Comments
Contract Details
Approval Date
7/17/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Leslie Simmons, Interim President
(410) 601-7346
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2019
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