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WALGREENS SPECIALTY PHARMACY, LLC
DSH140174 PRESENCE MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
PRESENCE MERCY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140174
Entity Address
1325 NORTH HIGHLAND AVENUE, ATTN: ADMINISTRATION
AURORA, IL 60506
Medicare Provider Number
140174
Participating Start Date
4/1/2010
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
10/27/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Larkin, Regional CFO
(630) 801-2729
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/27/2015
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