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WALGREEN CO.
DSH490022 MARY WASHINGTON HOSPITAL
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Covered Entity Details
Entity Name
MARY WASHINGTON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490022
Entity Address
1001 SAM PERRY BLVD
FREDERICKSBURG, VA 22401
Medicare Provider Number
490022
Participating Start Date
7/1/2024
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
WALGREENS #18211
11129 GORDON RD
FREDERICKSBURG, VA 22407-1714
Pharmacy Comments
Contract Details
Approval Date
7/10/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/19/2025
Pharmacy closed
Contacts
Covered Entity Signing Official
Sean Timothy Barden, Executive VP & CFO
(540) 741-1494
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/10/2024
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