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WALGREEN CO
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
WALGREEN CO
Pharmacy Address
DBA: WALGREENS # 09136
1625 W SUNSET BLVD
LOS ANGELES, CA 90026
Pharmacy Comments
Contract Details
Approval Date
7/15/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Raffoul, Senior VP, Finances
(323) 268-5000 Ext: 1969
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2015
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