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WALGREENS SPECIALTY PHARMACY, LLC
DSH050078A PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Subdivision Name
Crisis Stabilization Unit - Psychiatry
Type
Disproportionate Share Hospital
340B ID
DSH050078A
Entity Address
1386 W 7th Street
san pedro, CA 90732
Medicare Provider Number
050078
Outpatient Facility Provider Number
Participating Start Date
10/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
Pharmacy Comments
Contract Details
Approval Date
7/8/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/17/2019
Agreement registered in error
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
7/8/2019
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