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WALGREEN CO.
DSH440176 INDIAN PATH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
INDIAN PATH COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440176
Entity Address
2000 BROOKSIDE DRIVE
KINGSPORT, TN 37660-4627
Medicare Provider Number
440176
Participating Start Date
10/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #13891
429 N. STATE OF FRANKLIN RD.
JOHNSON CITY, TN 37604
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/12/2024
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