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WALGREEN CO.
DSH140182A ADVOCATE NORTH SIDE HEALTH NETWORK
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Covered Entity Details
Entity Name
ADVOCATE NORTH SIDE HEALTH NETWORK
Subdivision Name
ADVOCATE ILLINOIS MASONIC CRETICOS / Creticos Cancer Center
Type
Disproportionate Share Hospital
340B ID
DSH140182A
Entity Address
900 W. NELSON AVE
CHICAGO, IL 60657-6708
Medicare Provider Number
140182
Outpatient Facility Provider Number
Participating Start Date
4/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #15197
6121 N BROADWAY ST.
CHICAGO, IL 60660
Pharmacy Comments
Contract Details
Approval Date
1/11/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/11/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
William Forslev, Chief Pharmacy Officer
(630) 929-5934
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/11/2018
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