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WALGREEN ARIZONA DRUG CO.
DSH450132 MEDICAL CENTER HOSPITAL
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Covered Entity Details
Entity Name
MEDICAL CENTER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450132
Entity Address
500 WEST 4TH ST.
ODESSA, TX 79761-5001
Medicare Provider Number
450132
Participating Start Date
4/1/1998
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
10/4/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matt D Collins, Vice President of Operations
(432) 640-2445
Contract Pharmacy Representative
Walgreens
Sharon Huiett, Analyst, 340B Client Relationship
(847) 964-8687
Signed By Date
10/4/2021
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