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WALGREEN CO.
DSH140181 SOUTH SHORE HOSPITAL CORPORATION
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Covered Entity Details
Entity Name
SOUTH SHORE HOSPITAL CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140181
Entity Address
8012 SOUTH CRANDON AVENUE
CHICAGO, IL 60617-1175
Medicare Provider Number
140181
Participating Start Date
4/1/2022
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09357
833 W 115TH ST
CHICAGO, IL 60643-4619
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/9/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Leslie M. Rogers, CEO
(773) 356-5200
Contract Pharmacy Representative
Walgreen Co
Bradley Hedstrom, Account Manager Health Systems
(224) 515-6021
Signed By Date
7/7/2022
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