Contract Pharmacy Details

WALGREEN CO.
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY

Covered Entity Details

Entity Name

SSM HEALTH-ST. MARYS-JEFFERSON CITY

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH260011

Entity Address

2505 Mission Drive
JEFFERSON CITY, MO 65109

Medicare Provider Number

260011

Participating Start Date

7/1/2022

Last Recertification Date

9/1/2024

Entity Termination Date

7/1/2025

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #16552
628 N NEW BALLAS RD STE A
CREVE COEUR, MO 63141

Pharmacy Comments

Contract Details

Approval Date

10/17/2022

Contract Begin Date

1/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Karen D. Rewerts, System VP of Finance
(557) 203-3614

Contract Pharmacy Representative

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

Signed By Date

10/17/2022

340B Drug Pricing Program Database