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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 # 06700
5224 COLDWATER CANYON AVE
VAN NUYS, CA 91401-6146
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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