Contract Pharmacy Details

WALGREEN CO.
CAH521338-00 PRAIRIE RIDGE HEALTH, INC.

Covered Entity Details

Entity Name

PRAIRIE RIDGE HEALTH, INC.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH521338-00

Entity Address

1515 PARK AVENUE
COLUMBUS, WI 53925-1618

Medicare Provider Number

521338

Participating Start Date

1/1/2014

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #10925
546 N GRAND AVE
SUN PRAIRIE, WI 53590

Pharmacy Comments

Contract Details

Approval Date

1/11/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Melissa S. Mangan, Vice President of Finance/Chief Financial Officer
(920) 623-1369

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