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WALGREEN CO.
DSH360239 SYCAMORE HOSPITAL
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Covered Entity Details
Entity Name
SYCAMORE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360239
Entity Address
4000 Miamisburg-Centerville Rd
MIAMISBURG, OH 45342
Medicare Provider Number
360239
Participating Start Date
1/1/2017
Last Recertification Date
9/10/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04520
1260 E CENTRAL
MIAMISBURG, OH 45342
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Brent Davis, CFO
(937) 395-8688
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2020
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