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WALGREENS SPECIALTY PHARMACY, LLC
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
ALLIANCERX WALGREENS PRIME #12314
9775 SW GEMINI DR, STE 1
BEAVERTON, OR 97008
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Stephen A. Hargett, CFO
(843) 792-6461
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/15/2016
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