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WALGREEN CO
DSH160067 MercyOne Waterloo Medical Center
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Covered Entity Details
Entity Name
MercyOne Waterloo Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160067
Entity Address
3421 W 9TH STREET
WATERLOO, IA 50702
Medicare Provider Number
160067
Participating Start Date
1/1/2011
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #10855
1850 LOGAN AVE
WATERLOO, IA 50703
Pharmacy Comments
Contract Details
Approval Date
4/3/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHELE PANICUCCI, SENIOR VP/CFO
(319) 272-7359
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/3/2015
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