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WALGREENS SPECIALTY PHARMACY, LLC
DSH320084 ROOSEVELT GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ROOSEVELT GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320084
Entity Address
42121 US HIGHWAY 70
PORTALES, NM 88130
Medicare Provider Number
320084
Participating Start Date
1/1/2017
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William E. Boyer, Chief Financial Officer
(575) 359-1800 Ext: 3416
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/14/2019
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