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WALGREEN CO.
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 00258
1650 W CHICAGO AVE
CHICAGO, IL 60622
Pharmacy Comments
Contract Details
Approval Date
4/30/2012
Contract Begin Date
4/30/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Charles Weis, EVP/CFO
(773) 257-6642
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
12/27/2011
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