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WALGREEN CO.
DSH340003 NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY
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Covered Entity Details
Entity Name
NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340003
Entity Address
830 ROCKFORD STREET
MOUNT AIRY, NC 27030
Medicare Provider Number
340003
Participating Start Date
7/1/2004
Last Recertification Date
9/5/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #10086
2069 ROCKFORD ST.
MOUNT AIRY, NC 27030
Pharmacy Comments
Contract Details
Approval Date
10/24/2012
Contract Begin Date
10/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
ROBERT G. HETRICK, CFO
(336) 719-7102
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/10/2012
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