Contract Pharmacy Details

WALGREEN CO.
DSH150002 THE METHODIST HOSPITALS

Covered Entity Details

Entity Name

THE METHODIST HOSPITALS

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH150002

Entity Address

600 GRANT ST
GARY, IN 46402

Medicare Provider Number

150002

Participating Start Date

4/1/2003

Last Recertification Date

9/4/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 04276
9280 WICKER AVE.
ST JOHN, IN 46373

Pharmacy Comments

Contract Details

Approval Date

10/7/2021

Contract Begin Date

1/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Matthew Shawn Doyle, President & CEO
(219) 886-4608

Contract Pharmacy Representative

Methodist
Jacquelyn Ivankovic, Associate Director of Pharmacy
(219) 738-5807

Signed By Date

10/7/2021

340B Drug Pricing Program Database