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WALGREEN CO
RRC230130-00 WILLIAM BEAUMONT HOSPITAL dba Beaumont Hospital - Royal Oak
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Covered Entity Details
Entity Name
WILLIAM BEAUMONT HOSPITAL dba Beaumont Hospital - Royal Oak
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230130-00
Entity Address
3601 WEST 13 MILE ROAD
ROYAL OAK, MI 48073-6769
Medicare Provider Number
230130
Participating Start Date
4/1/2017
Last Recertification Date
8/30/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #11456
25700 FORD RD
DEARBORN HEIGHTS, MI 48127
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lee Ann Odom, President, Shared Services
(947) 522-2653
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/13/2022
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