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WALGREEN CO.
FQHCLA421C TARZANA TREATMENT CENTER, INC.
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Covered Entity Details
Entity Name
TARZANA TREATMENT CENTER, INC.
Subdivision Name
Tarzana Treatment Centers-Palmdale
Type
Health Center Program Look-Alike
340B ID
FQHCLA421C
Entity Address
320 E Palmdale Blvd
Palmdale, CA 93550-4598
Grant Number
LALCS40177
Participating Start Date
4/1/2021
Last Recertification Date
2/11/2025
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
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