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WALGREEN CO.
DSH010001 SOUTHEAST HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHEAST HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010001
Entity Address
1108 ROSS CLARK CIRCLE
DOTHAN, AL 36301
Medicare Provider Number
010001
Participating Start Date
7/1/2024
Last Recertification Date
8/26/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07404
2041 E MAIN STREET
DOTHAN, AL 36301
Pharmacy Comments
Contract Details
Approval Date
12/5/2011
Contract Begin Date
12/5/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/2/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DEREK R. MILLER, SR. VP FINANCE, CFO
(334) 793-8815
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
11/24/2011
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