Contract Pharmacy Details

WALGREEN CO.
DSH320011 ESPANOLA HOSPITAL

Covered Entity Details

Entity Name

ESPANOLA HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH320011

Entity Address

1010 SPRUCE STREET
ESPANOLA, NM 87532

Medicare Provider Number

320011

Participating Start Date

4/1/2005

Last Recertification Date

8/28/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 05157
1115 N. RIVERSIDE DR.
ESPANOLA, NM 87532

Pharmacy Comments

Contract Details

Approval Date

11/14/2012

Contract Begin Date

11/14/2012

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

ROBERT GARCIA, VP-OPERATIONS, REGIONAL DELIVERY SYSTEM
(505) 923-5339

Contract Pharmacy Representative

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

Signed By Date

11/14/2012

340B Drug Pricing Program Database