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WALGREEN CO.
DSH490017 Maryview Hospital LLC
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Covered Entity Details
Entity Name
Maryview Hospital LLC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490017
Entity Address
3636 HIGH ST
PORTSMOUTH, VA 23707
Medicare Provider Number
490017
Participating Start Date
4/1/2009
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04616
700 FREDERICK BLVD
PORTSMOUTH, VA 23707
Pharmacy Comments
Contract Details
Approval Date
1/21/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph M. Oddis, CEO
(757) 398-2135
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/21/2015
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