Contract Pharmacy Details

WALGREEN CO.
DSH050079 DOCTORS MEDICAL CENTER

Covered Entity Details

Entity Name

DOCTORS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050079

Entity Address

2000 VALE ROAD
SAN PABLO, CA 94806

Medicare Provider Number

050079

Participating Start Date

1/1/2007

Last Recertification Date

9/3/2014

Entity Termination Date

4/24/2015

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 04491
15650 SAN PABLO AVE.
SAN PABLO, CA 94806

Pharmacy Comments

Contract Details

Approval Date

10/9/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/24/2015
Covered Entity Terminated

Contacts

Covered Entity Signing Official

JAMES BOATMAN, CFO
(510) 970-5024

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/9/2013

340B Drug Pricing Program Database