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WHITE MEM MED PLAZA PHARMACY
DSH050103 WHITE MEMORIAL MEDICAL CENTER, DBA Adventist Health White Memorial
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Covered Entity Details
Entity Name
WHITE MEMORIAL MEDICAL CENTER, DBA Adventist Health White Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050103
Entity Address
1720 EAST CESAR E CHAVEZ AVENUE
LOS ANGELES, CA 90033
Medicare Provider Number
050103
Participating Start Date
7/1/2005
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WHITE MEM MED PLAZA PHARMACY
Pharmacy Address
1701 CESAR CHAVEZ AVE SUITE 109
LOS ANGELES, CA 90033
Pharmacy Comments
Contract Details
Approval Date
4/6/2012
Contract Begin Date
4/6/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2018
Ownership change
Contacts
Covered Entity Signing Official
John Raffoul, Senior VP, Finances
(323) 268-5000 Ext: 1969
Contract Pharmacy Representative
Mini Pharmacy
Richard Fox, Vice President
(323) 221-6000
Signed By Date
3/2/2012
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