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WALGREEN CO
DSH110007 PHOEBE PUTNEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PHOEBE PUTNEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110007
Entity Address
417 WEST THIRD AVENUE
ALBANY, GA 31701
Medicare Provider Number
110007
Participating Start Date
10/1/2003
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #10796
2414 SYLVESTER RD
ALBANY, GA 31705
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Church, CFO & CAO
(229) 312-4066
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2021
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