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WALGREEN CO.
DSH050017 MERCY GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MERCY GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050017
Entity Address
4001 J STREET
SACRAMENTO, CA 95819
Medicare Provider Number
050017
Participating Start Date
4/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12365
8275 BRUCEVILLE RD
SACRAMENTO, CA 95823
Pharmacy Comments
Contract Details
Approval Date
10/16/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Miranda, CFO
(916) 453-4459
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/16/2013
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