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WALGREEN CO.
RRC140034-00 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
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Covered Entity Details
Entity Name
ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140034-00
Entity Address
400 NORTH PLEASANT AVENUE
CENTRALIA, IL 62801
Medicare Provider Number
140034
Participating Start Date
4/1/2011
Last Recertification Date
9/19/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 07236
225 NORTH ELM STREET
CENTRALIA, IL 62801-3248
Pharmacy Comments
Contract Details
Approval Date
10/16/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Sigsbury, PRESIDENT
(618) 436-6525
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/16/2015
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