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WALGREEN CO.
DSH240002 ST MARYS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST MARYS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240002
Entity Address
402 E 2ND STREET
DULUTH, MN 55805
Medicare Provider Number
240002
Participating Start Date
7/1/2011
Last Recertification Date
8/30/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 03064
2015 TOWER AVENUE
SUPERIOR, WI 54880
Pharmacy Comments
Contract Details
Approval Date
1/19/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bradley Beard, Chief Operating Officer
(218) 786-2652
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/19/2022
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