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WALGREEN CO.
DSH140191 INGALLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INGALLS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140191
Entity Address
ONE INGALLS DRIVE
HARVEY, IL 60426
Medicare Provider Number
140191
Participating Start Date
9/22/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS SPECIALTY PHARMACY #16498
2351 E 71ST ST
SUITE A
CHICAGO, IL 60649
Pharmacy Comments
Contract Details
Approval Date
7/13/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/9/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KURT E. JOHNSON, CEO
(708) 915-6101
Contract Pharmacy Representative
Ingalls
Jennifer Halsey, Director of Pharmacy Services
(708) 915-4406
Signed By Date
7/13/2017
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