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WALGREEN CO
DSH050079 DOCTORS MEDICAL CENTER
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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 #11614
2750 PINOLE VALLEY RD
PINOLE, CA 94564
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
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