Contract Pharmacy Details

WALGREEN CO
DSH250058 SOUTH CENTRAL REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

SOUTH CENTRAL REGIONAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH250058

Entity Address

1220 JEFFERSON STREET
LAUREL, MS 39440

Medicare Provider Number

250058

Participating Start Date

7/1/2004

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO

Pharmacy Address

DBA: WALGREENS #12929
804 SPRING STREET
WAYNESBORO, MS 39367

Pharmacy Comments

Contract Details

Approval Date

7/14/2021

Contract Begin Date

9/10/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

James T. Canizaro, CFO
(601) 399-6139

Contract Pharmacy Representative

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

Signed By Date

7/14/2021

340B Drug Pricing Program Database