Contract Pharmacy Details

WALGREEN CO.
FQHCLA421B TARZANA TREATMENT CENTER, INC.

Covered Entity Details

Entity Name

TARZANA TREATMENT CENTER, INC.

Subdivision Name

Tarzana Treatment Centers- Antelope Valley Family Medical Clinic

Type

Health Center Program Look-Alike

340B ID

FQHCLA421B

Entity Address

907 W Lancaster Blvd
Lancaster, CA 93534-2305

Grant Number

LALCS40177

Participating Start Date

4/1/2021

Last Recertification Date

2/27/2025

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #15293
4940 VAN NUYS BLVD STE 104
SHERMAN OAKS, CA 91403

Pharmacy Comments

Contract Details

Approval Date

4/8/2021

Contract Begin Date

4/19/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

ALBERT M. SENELLA, PRESIDENT AND CEO
(818) 654-3815

Contract Pharmacy Representative

Walgreens
Ted Kountouris, Regional Manager
(626) 806-1853

Signed By Date

4/8/2021

340B Drug Pricing Program Database