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WALGREEN CO.
DSH420069 CLARENDON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CLARENDON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420069
Entity Address
10 HOSPITAL STREET
MANNING, SC 29102
Medicare Provider Number
420069
Participating Start Date
1/1/2005
Last Recertification Date
8/28/2015
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09276
1990 MCCRAYS MILL RD.
SUMTER, SC 29150-6185
Pharmacy Comments
Contract Details
Approval Date
10/27/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2016
Contacts
Covered Entity Signing Official
Richard Stokes, CEO
(803) 435-3239
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/27/2015
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