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MICHAEL'S PHARMACY
DSH050158 ENCINO HOSPITAL
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Covered Entity Details
Entity Name
ENCINO HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050158
Entity Address
16237 VENTURA BLVD
ENCINO, CA 91436
Medicare Provider Number
050158
Participating Start Date
1/1/2018
Last Recertification Date
8/22/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
MICHAEL'S PHARMACY
Pharmacy Address
6640 VAN NUYS BLVD STE 203
VAN NUYS, CA 91405
Pharmacy Comments
Contract Details
Approval Date
7/20/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bockhi Park, Chief Executive Officer
(818) 907-4540
Contract Pharmacy Representative
Michael's Pharmacy
Babak Reuben Kohanteb, owner
(818) 905-0669
Signed By Date
7/20/2018
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