Contract Pharmacy Details

WALGREEN CO.
DSH450213 UNIVERSITY HEALTH SYSTEM

Covered Entity Details

Entity Name

UNIVERSITY HEALTH SYSTEM

Subdivision Name

UNIVERSITY HOSPITAL

Type

Disproportionate Share Hospital

340B ID

DSH450213

Entity Address

4502 MEDICAL DRIVE
SAN ANTONIO, TX 78229

Medicare Provider Number

450213

Participating Start Date

10/1/1993

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #12479
121 N. ZARZAMORA ST.
SAN ANTONIO, TX 78207-3739

Pharmacy Comments

Contract Details

Approval Date

9/14/2012

Contract Begin Date

9/14/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/14/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

MARY ANN MOTE, CHIEF REVENUE OFFICER
(210) 358-2895

Contract Pharmacy Representative

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

Signed By Date

9/14/2012

340B Drug Pricing Program Database