340B Drug Pricing Program Database
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WALGREEN CO.
DSH130025 MADISON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130025
Entity Address
450 EAST MAIN
REXBURG, ID 83440
Medicare Provider Number
130025
Participating Start Date
7/1/2009
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09918
164 E MAIN ST
REXBURG, ID 83440-1912
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2020
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