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WALGREEN CO
DSH040017B NORTH ARKANSAS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH ARKANSAS REGIONAL MEDICAL CENTER
Subdivision Name
MARSHALL FAMILY PRACTICE CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH040017B
Entity Address
211 AIRPORT ROAD
MARSHALL, AR 72650
Medicare Provider Number
040017
Outpatient Facility Provider Number
Participating Start Date
10/1/2010
Last Recertification Date
8/15/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #12268
101 INDUSTRIAL PARK DRIVE
HOLLISTER, MO 65672
Pharmacy Comments
Contract Details
Approval Date
10/12/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sammie Cribbs, Chief Executive Officer
(870) 414-5159
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/12/2022
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