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WALGREEN CO.
SCH060044-00 Centura St. Elizabeth Hospital
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Covered Entity Details
Entity Name
Centura St. Elizabeth Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH060044-00
Entity Address
1000 Lincoln Street
Fort Morgan, CO 80701
Medicare Provider Number
060044
Participating Start Date
4/1/2023
Last Recertification Date
8/28/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09979
111 EAST PLATTE AVENUE
FT MORGAN, CO 80701
Pharmacy Comments
Contract Details
Approval Date
3/9/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Derick Lorentz, CFO
(970) 542-4673
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/17/2023
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