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WALGREEN CO.
CAH521329-00 ST MARYS HOSPITAL OF SUPERIOR
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Covered Entity Details
Entity Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521329-00
Entity Address
3500 TOWER AVE
SUPERIOR, WI 54880
Medicare Provider Number
521329
Participating Start Date
9/30/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 03064
2015 TOWER AVENUE
SUPERIOR, WI 54880
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
Terry Jacobson, Administrator
(715) 817-7014
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2020
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