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WALGREENS SPECIALTY PHARMACY, LLC
DSH520087 Gundersen Lutheran Medical Center, Inc.
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Covered Entity Details
Entity Name
Gundersen Lutheran Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520087
Entity Address
1900 South Ave
La Crosse, WI 54601
Medicare Provider Number
520087
Participating Start Date
7/1/2012
Last Recertification Date
9/6/2024
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
5/17/2021
Contract Begin Date
5/19/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kay P Marsyla, Director, Reimbursement
(608) 775-0171
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
5/17/2021
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