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WALGREEN CO.
DSH450032 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450032
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450032
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11175
701 US HIGHWAY 259 N
KILGORE, TX 75662-6041
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Keith Creel, Vice President of Ancillary Services
(903) 927-6797
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/17/2017
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