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WALGREEN CO
PED053302-00 Childrens Hospital Los Angeles
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Covered Entity Details
Entity Name
Childrens Hospital Los Angeles
Subdivision Name
Type
Children's Hospital
340B ID
PED053302-00
Entity Address
4650 Sunset Boulevard
Room 1401
Los Angeles, CA 90027
Medicare Provider Number
053302
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #09491
10955 MAGNOLIA BLVD
NORTH HOLLYWOOD, CA 91601
Pharmacy Comments
Contract Details
Approval Date
12/6/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rod Hanners, Chief Operating Officer
(323) 361-2301
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2013
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