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WALGREENS SPECIALTY PHARMACY, LLC
DSH490063 INOVA FAIRFAX HOSPITAL
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Covered Entity Details
Entity Name
INOVA FAIRFAX HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490063
Entity Address
3300 Gallows Road
Falls Church, VA 22042
Medicare Provider Number
490063
Participating Start Date
10/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
ALLIANCERX WALGREENS PRIME #12314
9775 SW GEMINI DR, STE 1
BEAVERTON, OR 97008
Pharmacy Comments
Contract Details
Approval Date
4/16/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
anuj steve narang, President
(480) 737-1397
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/16/2020
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