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WALGREEN CO.
DSH050457 UCSF HEALTH - ST. MARY'S HOSPITAL
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Covered Entity Details
Entity Name
UCSF HEALTH - ST. MARY'S HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050457
Entity Address
450 STANYAN STREET
SAN FRANCISCO, CA 94117
Medicare Provider Number
050457
Participating Start Date
1/1/2007
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 03849
745 CLEMENT ST
SAN FRANCISCO, CA 94118
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/25/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sherie Ambrose, Vice President/ Chief Nurse Executive/ COO
(415) 750-5716
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/11/2019
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