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WALGREEN CO.
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS #16093
3040 S. CICERO AVE.
SUITE A
CICERO, IL 60804
Pharmacy Comments
Contract Details
Approval Date
1/27/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sameer Shah, President, Mount Sinai Hospital Medical Center
(773) 257-2012
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/27/2023
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