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MICHAEL'S PHARMACY
DSH050755 SHERMAN OAKS HOSPITAL-HLTH
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Covered Entity Details
Entity Name
SHERMAN OAKS HOSPITAL-HLTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050755
Entity Address
4929 VAN NUYS BLVD
SHERMAN OAKS, CA 91403
Medicare Provider Number
050755
Participating Start Date
10/1/2017
Last Recertification Date
8/21/2019
Entity Termination Date
10/1/2019
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
10/1/2019
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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