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WALGREEN CO.
DSH050300 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050300
Entity Address
18300 US HIGHWAY 18
APPLE VALLEY, CA 92307
Medicare Provider Number
050300
Participating Start Date
10/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA:WALGREENS #12576
15318 ROY ROGERS DR.
VICTORVILLE, CA 92394
Pharmacy Comments
Contract Details
Approval Date
10/1/2012
Contract Begin Date
10/1/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Perring-Mulligan, Vice President of Mission Integration
(760) 242-2311 Ext: 8204
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
9/30/2012
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