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GLENDALE WEST PHARMACY
DSH050239 GLENDALE ADVENTIST MEDICAL CENTER
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Covered Entity Details
Entity Name
GLENDALE ADVENTIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050239
Entity Address
1509 WILSON TERRACE
GLENDALE, CA 91206
Medicare Provider Number
050239
Participating Start Date
4/1/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
GLENDALE WEST PHARMACY
Pharmacy Address
1109 S GLENDALE AVENUE
SUITES A AND B
GLENDALE, CA 91205
Pharmacy Comments
Contract Details
Approval Date
4/17/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/11/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kelly Turner, Senior VP Finance
(818) 409-8289
Contract Pharmacy Representative
Malek set Allahdadi, Owner
(818) 548-5157
Signed By Date
4/17/2013
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