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WALGREEN CO.
CAH451356-00 MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451356-00
Entity Address
815 N VIRGINIA STREET
PORT LAVACA, TX 77979
Medicare Provider Number
451356
Participating Start Date
9/16/2010
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12494
1302 N. VIRGINIA ST.
PORT LAVACA, TX 77979
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON ANGLIN, CEO
(361) 552-6713 Ext: 240
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/17/2017
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