Contract Pharmacy Details

WALGREEN CO.
DSH140223 ADVOCATE LUTHERAN GENERAL HOSPITAL

Covered Entity Details

Entity Name

ADVOCATE LUTHERAN GENERAL HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140223

Entity Address

1775 W. DEMPSTER STREET
PARK RIDGE, IL 60068

Medicare Provider Number

140223

Participating Start Date

10/1/2016

Last Recertification Date

Entity Termination Date

7/1/2017

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 00209
1028 S ELMHURST ROAD
MT PROSPECT, IL 60056

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

7/1/2017

Contacts

Covered Entity Signing Official

Lizabeth Hickey, Interim VP Finance
(847) 723-2220

Contract Pharmacy Representative

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

Signed By Date

10/17/2016

340B Drug Pricing Program Database