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WALGREEN CO
DSH050112 SANTA MONICA UCLAMC AND ORTHOPAEDIC HOSPITAL
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Covered Entity Details
Entity Name
SANTA MONICA UCLAMC AND ORTHOPAEDIC HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050112
Entity Address
1250 16TH STREET
SANTA MONICA, CA 90404-1249
Medicare Provider Number
050112
Participating Start Date
7/1/2009
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #9882
331 N PACIFIC COAST HWY
EL SEGUNDO, CA 90245-4444
Pharmacy Comments
Contract Details
Approval Date
7/11/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Staton, CFO
(310) 267-9308
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/11/2018
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