Contract Pharmacy Details

WALGREEN CO.
DSH140250 SOUTH SUBURBAN HOSPITAL

Covered Entity Details

Entity Name

SOUTH SUBURBAN HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140250

Entity Address

17800 Kedzie Ave
HAZELCREST, IL 60429

Medicare Provider Number

140250

Participating Start Date

10/1/2016

Last Recertification Date

11/9/2017

Entity Termination Date

7/1/2018

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #15460
4440 WEST 95TH STREET SUITE 0201P
OAK LAWN, IL 60453

Pharmacy Comments

Contract Details

Approval Date

10/24/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Brian Kelly, VP Finance, Advocate Trinity Hospital
(708) 213-3004

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/24/2016

340B Drug Pricing Program Database