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WALGREEN CO.
DSH050113 SAN MATEO MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN MATEO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050113
Entity Address
222 WEST 39TH AVENUE
SAN MATEO, CA 94403
Medicare Provider Number
050113
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 02126
1414 EL CAMINO REAL
SAN CARLOS, CA 94070
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/17/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHESTER J. KUNNAPPILLY, CEO
(650) 573-2305
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2016
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