Contract Pharmacy Details

WALGREEN CO.
DSH210013 Grace Medical Center, Inc.

Covered Entity Details

Entity Name

Grace Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH210013

Entity Address

2000 WEST BALTIMORE STREET
BALTIMORE, MD 21223

Medicare Provider Number

210013

Participating Start Date

10/1/2002

Last Recertification Date

9/10/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #16188
2000 W. BALTIMORE STREET
BALTIMORE, MD 21223

Pharmacy Comments

Contract Details

Approval Date

5/8/2014

Contract Begin Date

5/8/2014

Carve-In Effective Date

Contract Comments

5/8/2014 - Immediate begin date authorized

Contract Termination Date
Termination Reason

4/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

RICHARD JONES, CFO
(410) 362-3716

Contract Pharmacy Representative

Pavithra Chigateri, Director of 340B Implementations
(847) 315-3519

Signed By Date

5/1/2014

340B Drug Pricing Program Database