Contract Pharmacy Details

WALGREENS SPECIALTY PHARMACY, LLC
RRC140250-00 SOUTH SUBURBAN HOSPITAL

Covered Entity Details

Entity Name

SOUTH SUBURBAN HOSPITAL

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140250-00

Entity Address

178TH STREET AND KEDZIE AVE
HAZELCREST, IL 60429

Medicare Provider Number

140250

Participating Start Date

10/1/2020

Last Recertification Date

Entity Termination Date

12/21/2020

Pharmacy Details

Pharmacy Name

WALGREENS SPECIALTY PHARMACY, LLC

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188

Pharmacy Comments

Contract Details

Approval Date

10/14/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/21/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Nan Nelson, SVP-Finance
(414) 378-4765

Contract Pharmacy Representative

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

Signed By Date

10/14/2020

340B Drug Pricing Program Database