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WALGREEN CO.
DSH370037 SSM ST ANTHONY HOSPITAL
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Covered Entity Details
Entity Name
SSM ST ANTHONY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370037
Entity Address
1000 N Lee Ave
OKLAHOMA CITY, OK 73102
Medicare Provider Number
370037
Participating Start Date
10/1/2006
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04066
1099 GARTH BROOKS BLVD.
YUKON, OK 73099
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shasta Manuel, Regional Vice President Finance/CFO
(405) 272-7279
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/16/2015
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