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WALGREEN EASTERN CO., INC
DSH330047 ST. MARYS HEALTHCARE
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Covered Entity Details
Entity Name
ST. MARYS HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330047
Entity Address
427 GUY PARK AVENUE
AMSTERDAM, NY 12010
Medicare Provider Number
330047
Participating Start Date
10/1/2009
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC
Pharmacy Address
WALGREENS #17492
9 E GRAND ST
PALATINE BRIDGE, NY 13428
Pharmacy Comments
Contract Details
Approval Date
3/29/2018
Contract Begin Date
4/2/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rick Henze, Vice President of Finance/CFO
(518) 841-7435
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
3/29/2018
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