Contract Pharmacy Details

WALGREEN CO.
DSH320038 REHOBOTH MCKINLEY CHRISTIAN HOSPITAL

Covered Entity Details

Entity Name

REHOBOTH MCKINLEY CHRISTIAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH320038

Entity Address

1901 RED ROCK DRIVE
GALLUP, NM 87301

Medicare Provider Number

320038

Participating Start Date

3/22/2022

Last Recertification Date

9/11/2023

Entity Termination Date

10/1/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 09007
1870 E HISTORIC HWY 66
GALLUP, NM 87301

Pharmacy Comments

Contract Details

Approval Date

3/22/2022

Contract Begin Date

3/22/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Chantelle Venter, I-CFO
(805) 215-5164

Contract Pharmacy Representative

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

Signed By Date

3/11/2022

340B Drug Pricing Program Database