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WALGREEN CO.
DSH160067 MercyOne Waterloo Medical Center
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Covered Entity Details
Entity Name
MercyOne Waterloo Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160067
Entity Address
3421 W 9TH STREET
WATERLOO, IA 50702
Medicare Provider Number
160067
Participating Start Date
1/1/2011
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS SPECIALTY PHARMACY #21254
2265 N MAYFAIR RD.
WAUWATOSA, WI 53226
Pharmacy Comments
Contract Details
Approval Date
1/12/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Douglas Davenport, Chief Financial Officer
(319) 272-7359
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2020
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