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WALGREEN CO.
DSH170086 STORMONT-VAIL HEALTHCARE INC.
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Covered Entity Details
Entity Name
STORMONT-VAIL HEALTHCARE INC.
Subdivision Name
DBA STORMONT VAIL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH170086
Entity Address
1500 SW 10TH AVE
TOPEKA, KS 66604
Medicare Provider Number
170086
Participating Start Date
4/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 04782
3696 SW TOPEKA BLVD
TOPEKA, KS 66611
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Robert Odin Langland, Sr VP Finance
(785) 354-6148
Contract Pharmacy Representative
Walgreens
Corine Zawiski, Client Relationship Analyst
(847) 964-8761
Signed By Date
4/10/2018
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