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WALGREENS SPECIALTY PHARMACY, LLC
CAH521338-00 PRAIRIE RIDGE HEALTH, INC.
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Covered Entity Details
Entity Name
PRAIRIE RIDGE HEALTH, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521338-00
Entity Address
1515 PARK AVENUE
COLUMBUS, WI 53925-1618
Medicare Provider Number
521338
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Phillip G. Roberts, Vice President and CFO
(920) 623-1368
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/6/2018
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