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Walgreen Arizona Drug Co.
DSH320038 REHOBOTH MCKINLEY CHRISTIAN HOSPITAL
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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 Arizona Drug Co.
Pharmacy Address
Walgreens Central Fill #21372
120 N 83rd Ave
200
Tolleson, AZ 85353
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
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
4/14/2022
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