Contract Pharmacy Details

WALGREEN CO.
DSH150104 WITHAM MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

WITHAM MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH150104

Entity Address

2605 N. LEBANON STREET
LEBANON, IN 46052

Medicare Provider Number

150104

Participating Start Date

5/19/2020

Last Recertification Date

9/12/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS SPECIALTY PHARMACY #16317
335 MASSACHUSETTS AVENUE
INDIANAPOLIS, IN 46204

Pharmacy Comments

Contract Details

Approval Date

4/14/2023

Contract Begin Date

7/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

George Pogas, SR VP of Finance/CFO
(765) 485-8102

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

4/14/2023

340B Drug Pricing Program Database