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WALGREEN CO.
DSH260175N GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
INTERNAL MEDICINE - CLINTON - RURAL HEALTH CLINIC II
Type
Disproportionate Share Hospital
340B ID
DSH260175N
Entity Address
1602 NORTH SECOND STREET
CLINTON, MO 64735
Medicare Provider Number
260175
Outpatient Facility Provider Number
Participating Start Date
10/1/2021
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09382
412 PAWNEE STREET
CLINTON, MO 64735-2481
Pharmacy Comments
Contract Details
Approval Date
1/3/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Nadler, CFO
(660) 890-7105
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/3/2023
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