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Walgreens Central Fill #21399
DSH140155 Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140155
Entity Address
500 West Court Street
Kankakee, IL 60901
Medicare Provider Number
140155
Participating Start Date
10/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
Walgreens Central Fill #21399
Pharmacy Address
4132Plainfield Rd
Ste 110
Indianapolis, IN 46231-7021
Pharmacy Comments
Contract Details
Approval Date
1/16/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael James Mulay, Regional CFO - Chicago Metro Region
(773) 990-8611
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/16/2023
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