Contract Pharmacy Details

WALGREEN ARIZONA DRUG CO.
RRC190027-00 ST. PATRICK HOSPITAL

Covered Entity Details

Entity Name

ST. PATRICK HOSPITAL

Subdivision Name

Type

Rural Referral Center

340B ID

RRC190027-00

Entity Address

524 DR. MICHAEL DEBAKEY DRIVE
LAKE CHARLES, LA 70601

Medicare Provider Number

190027

Participating Start Date

1/10/2022

Last Recertification Date

9/11/2023

Entity Termination Date

1/1/2024

Pharmacy Details

Pharmacy Name

WALGREEN ARIZONA DRUG CO.

Pharmacy Address

WALGREENS CENTRAL FILL #21372
120 N 83RD AVE
STE 200
TOLLESON, AZ 85353

Pharmacy Comments

Contract Details

Approval Date

10/14/2022

Contract Begin Date

1/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/14/2022
Agreement registered in error

Contacts

Covered Entity Signing Official

Paul Trevino, CEO, CHRISTUS Health Southeast Texas
(409) 899-7102

Contract Pharmacy Representative

Walgreens
Edwin Raff, DVP Contracting & Pricing
(847) 964-6198

Signed By Date

10/14/2022

340B Drug Pricing Program Database