Contract Pharmacy Details

WALGREEN CO.
DSH100087 SARASOTA MEMORIAL HOSPITAL

Covered Entity Details

Entity Name

SARASOTA MEMORIAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH100087

Entity Address

1700 S. TAMIAMI TRAIL
SARASOTA, FL 34239-3509

Medicare Provider Number

100087

Participating Start Date

1/1/2015

Last Recertification Date

11/16/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 01921
3506 CLARK ROAD
SARASOTA, FL 34231-8408

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/1/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

William Woeltjen, Chief Financial Officer
(941) 917-1280

Contract Pharmacy Representative

Angie Juliana, 340B Implementation Analyst
(847) 964-4889

Signed By Date

10/17/2016

340B Drug Pricing Program Database