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WAL-MART PHARMACY 10-5154
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
WAL-MART PHARMACY 10-5154
Pharmacy Address
1827 WALNUT GROVE AVE
ROSEMEAD, CA 91770
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Raffoul, Senior VP Finance
(323) 268-5000 Ext: 5847
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2013
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