Contract Pharmacy Details

WALGREEN CO.
DSH490114 LONESOME PINE HOSPITAL

Covered Entity Details

Entity Name

LONESOME PINE HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH490114

Entity Address

1990 HOLTON AVENUE EAST
BIG STONE GAP, VA 24219

Medicare Provider Number

490114

Participating Start Date

10/1/2006

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 09306
3900 FORT HENRY DRIVE
COLONIAL HEIGHTS, TN 37663-2026

Pharmacy Comments

Contract Details

Approval Date

3/16/2015

Contract Begin Date

4/1/2015

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Alice Pope, EVP and CFO
(423) 230-8209

Contract Pharmacy Representative

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

Signed By Date

3/16/2015

340B Drug Pricing Program Database