Contract Pharmacy Details

WALGREEN CO.
DSH060071 DELTA COUNTY MEMORIAL HOSPITAL

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 # 06108
572 32 ROAD
CLIFTON, CO 81520-7606

Pharmacy Comments

Contract Details

Approval Date

5/11/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/27/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jason Cleckler, CEO
(970) 874-2229

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

4/12/2018

340B Drug Pricing Program Database