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Walgreen CO
DSH160104 TRINITY BETTENDORF
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Covered Entity Details
Entity Name
TRINITY BETTENDORF
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160104
Entity Address
4500 UTICA RIDGE ROAD
BETTENDORF, IA 52722
Medicare Provider Number
160104
Participating Start Date
4/1/2017
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
Walgreen CO
Pharmacy Address
DBA Walgreens Central Fill #21417
599 S Schmidt Rd
Ste A
Bolingbrook, IL 60440-9405
Pharmacy Comments
Contract Details
Approval Date
1/10/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dave Dellitt, Chief Financial Officer
(309) 779-2218
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/10/2023
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