Contract Pharmacy Details

WALGREEN CO.
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER

Covered Entity Details

Entity Name

MOUNT SINAI HOSPITAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140018

Entity Address

2750 W 15TH PLACE
CHICAGO, IL 60608-1797

Medicare Provider Number

140018

Participating Start Date

10/1/2004

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 09470
4817 W FULLERTON AVE
CHICAGO, IL 60639-2503

Pharmacy Comments

Contract Details

Approval Date

7/17/2020

Contract Begin Date

8/28/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Michele Mazurek, Hospital Chief Administator
(773) 257-5021

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/17/2020

340B Drug Pricing Program Database