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WALGREEN CO.
SCH260050-00 Mosaic Medical Center Maryville
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Covered Entity Details
Entity Name
Mosaic Medical Center Maryville
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260050-00
Entity Address
2016 S. Main
Maryville, MO 64468
Medicare Provider Number
260050
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12821
1114 S MAIN ST
MARYVILLE, MO 64468
Pharmacy Comments
Contract Details
Approval Date
7/7/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Baumgartner, President
(660) 562-7900
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/7/2015
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