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WALGREEN CO
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
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #09491
10955 MAGNOLIA BLVD
NORTH HOLLYWOOD, CA 91601
Pharmacy Comments
Contract Details
Approval Date
1/21/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Business decision by covered entity and/or pharmacy
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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