Contract Pharmacy Details

WALGREEN CO.
DSH500002 PROV ST MARY MEDICAL CENTER

Covered Entity Details

Entity Name

PROV ST MARY MEDICAL CENTER

Subdivision Name

Providence St. Mary Medical Center

Type

Disproportionate Share Hospital

340B ID

DSH500002

Entity Address

401 W POPLAR ST.
WALLA WALLA, WA 99362-2846

Medicare Provider Number

500002

Participating Start Date

10/1/2022

Last Recertification Date

8/30/2023

Entity Termination Date

7/1/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

WALGREENS SPECIALTY PHARMACY #21243
327 W 3RD AVE
STE A
SPOKANE, WA 99201

Pharmacy Comments

Contract Details

Approval Date

8/31/2022

Contract Begin Date

10/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Spencer Dwayne Harris, CFO
(509) 942-2708

Contract Pharmacy Representative

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

Signed By Date

7/8/2022

340B Drug Pricing Program Database