Contract Pharmacy Details

WALGREEN CO.
DSH430077 Monument Health Rapid City Hospital

Covered Entity Details

Entity Name

Monument Health Rapid City Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH430077

Entity Address

353 FAIRMONT BLVD
RAPID CITY, SD 57701

Medicare Provider Number

430077

Participating Start Date

4/1/2004

Last Recertification Date

9/12/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #10656
1902 MOUNT RUSHMORE RD.
RAPID CITY, SD 57701-4621

Pharmacy Comments

Contract Details

Approval Date

7/18/2016

Contract Begin Date

10/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Michael Gibbs, PRESIDENT
(605) 755-8162

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

7/18/2016

340B Drug Pricing Program Database