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WALGREEN CO.
SCH160016-00 TRINITY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
TRINITY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160016-00
Entity Address
802 KENYON ROAD
FORT DODGE, IA 50501
Medicare Provider Number
160016
Participating Start Date
10/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05361
2503 5TH AVE. S.
FT DODGE, IA 50501
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brent Feickert, Chief Financial Officer
(515) 574-6617
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/16/2018
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