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WALGREEN CO
CAH151320-01 JAY COUNTY HOSPITAL
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Covered Entity Details
Entity Name
JAY COUNTY HOSPITAL
Subdivision Name
FAMILY PRACTICE OF JAY COUNTY
Type
Critical Access Hospital
340B ID
CAH151320-01
Entity Address
428 W VOTAW ST STE A
PORTLAND, IN 47371-1302
Medicare Provider Number
151320
Outpatient Facility Provider Number
Participating Start Date
10/1/2015
Last Recertification Date
11/3/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #12676
124 W VOTAW STREET
PORTLAND, IN 47371
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Don Michael, CFO
(260) 726-7131 Ext: 1018
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/14/2015
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