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WALGREEN CO.
DSH140185 MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140185
Entity Address
4500 MEMORIAL DRIVE
BELLEVILLE, IL 62226
Medicare Provider Number
140185
Participating Start Date
7/1/2024
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07672
1108 HARTMAN LANE
SHILOH, IL 62221
Pharmacy Comments
Contract Details
Approval Date
10/10/2022
Contract Begin Date
11/4/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael McManus, President
(618) 257-5642
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/10/2022
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