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WALGREENS SPECIALTY PHARMACY, LLC
DSH420071 SELF REGIONAL HEALTHCARE
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Covered Entity Details
Entity Name
SELF REGIONAL HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420071
Entity Address
1325 SPRING STREET
GREENWOOD, SC 29646
Medicare Provider Number
420071
Participating Start Date
1/1/2007
Last Recertification Date
8/24/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
4/6/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Evans, VICE PRESIDENT & CFO
(864) 725-4248
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/6/2017
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