Contract Pharmacy Details

CYSTIC FIBROSIS SERVICES, LLC
DSH050567 MISSION HOSPITAL

Covered Entity Details

Entity Name

MISSION HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050567

Entity Address

27700 Medical Center Road
Mission Viejo, CA 92691

Medicare Provider Number

050567

Participating Start Date

4/1/2016

Last Recertification Date

8/29/2018

Entity Termination Date

1/1/2019

Pharmacy Details

Pharmacy Name

CYSTIC FIBROSIS SERVICES, LLC

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033

Pharmacy Comments

Contract Details

Approval Date

7/12/2017

Contract Begin Date

7/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/11/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Eileen Haubl, Chief Financial Officer
(949) 364-1400 Ext: 5408

Contract Pharmacy Representative

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

Signed By Date

7/12/2017

340B Drug Pricing Program Database