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WALGREEN CO
DSH110087 Northside Hospital Gwinnett
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Covered Entity Details
Entity Name
Northside Hospital Gwinnett
Subdivision Name
Gwinnett Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH110087
Entity Address
1000 MEDICAL CENTER BLVD
LAWRENCEVILLE, GA 30046
Medicare Provider Number
110087
Participating Start Date
9/19/2005
Last Recertification Date
8/14/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
WALGREENS SPECIALTY PHARMACY #15131
631 PROFESSIONAL DRIVE STE 100
LAWRENCEVILLE, GA 30046
Pharmacy Comments
Contract Details
Approval Date
4/12/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
THOMAS Y. MCBRIDE III, Executive VP & CFO
(678) 312-4308
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2017
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