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CYSTIC FIBROSIS SERVICES, LLC
DSH150101 WHITLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WHITLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150101
Entity Address
1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492
Medicare Provider Number
150101
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeanne Wickens, CFO
(260) 373-8407
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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