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Walgreens #21435
CAH271343-00 Providence Saint Joseph Medical Center
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Covered Entity Details
Entity Name
Providence Saint Joseph Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271343-00
Entity Address
6-13th AVENUE EAST
POLSON, MT 59860
Medicare Provider Number
271343
Participating Start Date
10/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
Walgreens #21435
Pharmacy Address
Walgreens Central Fill #21435
6306 S Airport Rd
West Jordan, UT 84084-5601
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kirk Bodlovic, Chief Operating Officer
(406) 327-1740
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/13/2023
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