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WALGREEN ARIZONA DRUG CO.
DSH030024C ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
Subdivision Name
Trauma Clinic
Type
Disproportionate Share Hospital
340B ID
DSH030024C
Entity Address
500 West Thomas Rd
Suite 400
Phoenix, AZ 85013
Medicare Provider Number
030024
Outpatient Facility Provider Number
Participating Start Date
4/1/2014
Last Recertification Date
8/23/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
DBA; WALGREENS #09460
40663 N. GANTZEL RD
SAN TAN VALLEY, AZ 85140-7008
Pharmacy Comments
Contract Details
Approval Date
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/10/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Jackson, Chief Financial Officer
(602) 406-4618
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2019
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