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WALGREEN CO.
DSH450213 UNIVERSITY HEALTH SYSTEM
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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 # 00662
13430 SAN PEDRO AVE
SAN ANTONIO, TX 78216
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
10/28/2015
Business decision by covered entity and/or pharmacy
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
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