Contract Pharmacy Details

WALGREEN CO.
DSH210013 Grace Medical Center, Inc.

Covered Entity Details

Entity Name

Grace Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH210013

Entity Address

2000 WEST BALTIMORE STREET
BALTIMORE, MD 21223

Medicare Provider Number

210013

Participating Start Date

10/1/2002

Last Recertification Date

9/10/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #16191
2411 W. BELVEDERE AVENUE
SUITE 101
BALTIMORE, MD 21215

Pharmacy Comments

Contract Details

Approval Date

1/11/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Rebecca Altman, Vice President and Chief Integration Officer
(410) 601-9000

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

1/11/2022

340B Drug Pricing Program Database