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WALGREEN EASTERN CO., INC.
CAH331302-04 ELIZABETHTOWN COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
ELIZABETHTOWN COMMUNITY HOSPITAL
Subdivision Name
Smith House Health Center
Type
Critical Access Hospital
340B ID
CAH331302-04
Entity Address
39 Farrell Road
Willsboro, NY 12996
Medicare Provider Number
331302
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
WALGREENS #18030
1161 NYS ROUTE 9N
TICONDEROGA, NY 12883-3105
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/10/2024
Duplicate contract pharmacy record
Contacts
Covered Entity Signing Official
Alan Chardavoyne, CFO
(518) 873-3136
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/16/2018
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