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CYSTIC FIBROSIS SERVICES, LLC
DSH050235 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE SAINT JOSEPH MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050235
Entity Address
501 S BUENA VISTA STREET
BURBANK, CA 91505
Medicare Provider Number
050235
Participating Start Date
7/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
1/21/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Glenn Bales, Chief Financial Officer
(818) 847-3022
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/21/2020
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