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WALGREEN CO.
DSH060071 DELTA COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DELTA COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060071
Entity Address
1501 E. 3RD ST.
DELTA, CO 81416
Medicare Provider Number
060071
Participating Start Date
7/1/2018
Last Recertification Date
8/23/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #12805
499 E HAMPDEN AVE STE 150
ENGLEWOOD, CO 80113
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jason Cleckler, CEO
(970) 874-2229
Contract Pharmacy Representative
Walgreens
Erin Kayser, Health Systems Solutions Director
(949) 280-7219
Signed By Date
10/16/2017
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