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WALGREEN ARIZONA DRUG CO.
DSH320011 ESPANOLA HOSPITAL
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Covered Entity Details
Entity Name
ESPANOLA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320011
Entity Address
1010 SPRUCE STREET
ESPANOLA, NM 87532
Medicare Provider Number
320011
Participating Start Date
4/1/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
WALGREENS CENTRAL FILL #21372
120 N 83RD AVE
STE 200
TOLLESON, AZ 85353
Pharmacy Comments
Contract Details
Approval Date
7/9/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Scott Graham, VP-PDS Clinical Support Srvc
(505) 841-1872
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/9/2021
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