Contract Pharmacy Details

WALGREEN CO.
DSH140209 METHODIST MEDICAL CENTER OF ILLINOIS

Covered Entity Details

Entity Name

METHODIST MEDICAL CENTER OF ILLINOIS

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140209

Entity Address

221 NE GLEN OAK AVE.
PEORIA, IL 61636

Medicare Provider Number

140209

Participating Start Date

10/1/2006

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 03763
1011 PEORIA ST
WASHINGTON, IL 61571-2487

Pharmacy Comments

Contract Details

Approval Date

10/26/2012

Contract Begin Date

10/26/2012

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

DEBORAH R. SIMON, PRESIDENT AND CEO
(309) 672-5929

Contract Pharmacy Representative

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

Signed By Date

10/12/2012

340B Drug Pricing Program Database