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WALGREEN CO.
DSH050353 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050353
Entity Address
4101 TORRANCE BLVD.
TORRANCE, CA 90503
Medicare Provider Number
050353
Participating Start Date
4/1/2007
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15190
1399 ROXBURY DR
LOS ANGELES, CA 90035
Pharmacy Comments
Contract Details
Approval Date
10/16/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/20/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ted Wang, CFO
(310) 303-6114
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/16/2018
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