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WALGREEN CO.
DSH060012 St. Mary-Corwin Hospital
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Covered Entity Details
Entity Name
St. Mary-Corwin Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060012
Entity Address
1008 Minnequa Avenue
Pueblo, CO 81004
Medicare Provider Number
060012
Participating Start Date
4/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04721
2900 W NORTHERN AVE
PUEBLO, CO 81005
Pharmacy Comments
Contract Details
Approval Date
7/23/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/7/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Vanessa Kochevar, Chief Financial Officer
(719) 557-4668
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/23/2015
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