Covered Entity Details

DSH050231 POMONA VALLEY HOSPITAL MEDICAL CENTER (Active) - information as of 5/16/2025 11:19:53 PM

Main Details

Name

POMONA VALLEY HOSPITAL MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

Rural

340B ID

DSH050231

Medicare Provider Number

050231

Additional Details

Current Program Status

Active

Registration Date

11/27/2006

Participating Start Date

1/1/2007

Participating Approval Date

11/28/2006

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Pomona Valley Hospital Medical Center
Darlene Scafiddi, Executive Vice President Chief Operating Officer
(909) 865-9879

Primary Contact

Pomona Valley Hospital Medical Center
Clifford Hiroshige, Director of Pharmacy
(909) 865-9656

Addresses

Street Address

1798 NORTH GAREY AVENUE
POMONA, CA 91767

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA		1407813660

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	07/14/2016	10/01/2016		08/29/2016
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	07/14/2016	10/01/2016	09/11/2017	10/04/2017
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	07/14/2016	10/01/2016	09/11/2017	10/04/2017
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/03/2017	07/01/2017		04/03/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	07/14/2016	10/01/2016		08/29/2016
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	07/14/2016	10/01/2016	09/11/2017	10/04/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2 BOULDEN CIR STE 1		NEW CASTLE	DE	19720-3492	07/14/2016	10/01/2016	09/11/2017	10/04/2017
Contract Detail	ADVANCED PHARMACY SOLUTIONS	26611 CABOT RD STE B		LAGUNA HILLS	CA	92653-7031	10/14/2020	01/01/2021		01/01/2021
Contract Detail	ARTESIA MEDICAL PHARMACY	160 E ARTESIA ST	STE 135	POMONA	CA	91767-2900	01/12/2017	04/01/2017	07/01/2020	07/14/2020
Contract Detail	AVELLA OF SACRAMENTO, INC.	2288 AUBURN BLVD #102		SACRAMENTO	CA	95821	07/14/2016	10/01/2016	02/03/2022	02/08/2022
Contract Detail	BIOPLUS SPECIALTY INFUSION CA, LLC	19110 VAN NESS AVE.		TORRANCE	CA	90501	10/10/2019	01/01/2020	12/14/2021	12/14/2021
Contract Detail	BIOPLUS SPECIALTY PHARMACY CA	7373 LINCOLN WAY		GARDEN GROVE	CA	92841	10/10/2019	01/01/2020	08/26/2024	09/30/2024
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	10/15/2024	01/01/2025		01/01/2025
Contract Detail	BIOPLUS SPECIALTY PHARMACY, INC	3200 LAKE EMMA RD UNIT 1000		LAKE MARY	FL	32746	10/10/2019	01/01/2020	08/26/2024	09/30/2024
Contract Detail	BRIOVARX OF MAINE INC	DBA BRIOVARX	53 DARLING AVE	SOUTH PORTLAND	ME	04106	01/17/2017	04/01/2017	07/06/2020	07/14/2020
Contract Detail	BRIOVARX OF MASSACHUSETTS, LLC	D/B/A BRIOVARX	BLDG 2 - UNIT A 145 BODWELL STREET	AVON	MA	02322	01/17/2017	04/01/2017	07/06/2020	07/14/2020
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	07/15/2016	10/01/2016		08/29/2016
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/11/2021	01/01/2022		01/01/2022
Contract Detail	CBC CONVALESCENT CARE PHCY	CBC PROFESSIONAL PHARMACY, INC	716 E MISSION BLVD., STE B	POMONA	CA	91766	01/05/2017	04/01/2017	07/01/2020	07/14/2020
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	12310 WORLD TRADE DRIVE SUITE 100	SAN DIEGO	CA	92128	04/17/2017	07/01/2017		04/17/2017
Contract Detail	CORAM ALTERNATE SITE SERVICES, INC.	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2345 WATERS DRIVE	MENDOTA HEIGHTS	MN	55120	10/10/2022	01/01/2023		01/01/2023
Contract Detail	CORAM HEALTHCARE CORP OF SOUTHERN CALIFO	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	2710 MEDIA CENTER DRIVE, BLDG. #6, SUITE 150	LOS ANGELES	CA	90065	04/17/2017	07/01/2017	08/28/2022	10/09/2023
Contract Detail	CORAM HEALTHCARE CORP OF SOUTHERN CALIFO	DBA CORAM CVS/SPECIALTY INFUSION SERVICE	4355 EAST LOWELL STREET SUITE C	ONTARIO	CA	91761	04/17/2017	07/01/2017	03/25/2025	04/14/2025
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/11/2021	01/01/2022		01/01/2022
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/11/2021	01/01/2022		01/01/2022
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/11/2021	01/01/2022		01/01/2022
Contract Detail	CYSTIC FIBROSIS SERVICES	CYSTIC FIBROSIS SERVICES, INC	10530 JOHN W ELLIOTT DR, STE 200	FRISCO	TX	75033	07/14/2016	10/01/2016	08/09/2017	08/10/2017
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/03/2017	07/01/2017		07/03/2017
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	07/15/2021	07/26/2021	08/04/2022	08/09/2022
Contract Detail	EXPRESS PHARMACY	EXPRESS PHARMACY	752 E ARROW HWY	POMONA	CA	91767	01/13/2017	04/01/2017	05/17/2017	05/19/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08781	1485 S. GAREY AVE.	POMONA	CA	91766	01/04/2017	04/01/2017	06/12/2024	02/24/2025
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 08895	775 E. FOOTHILL BOULEVARD	POMONA	CA	91767	01/04/2017	04/01/2017		01/04/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09708	150 W. WILLOW ST.	POMONA	CA	91768	01/04/2017	04/01/2017		01/04/2017
Contract Detail	GARFIELD BEACH CVS, L.L.C.	DBA: CVS/PHARMACY # 09778	12101 CENTRAL AVE.	CHINO	CA	91710	01/04/2017	04/01/2017	04/01/2020	04/17/2020
Contract Detail	HENDRICKS PHARMACY	HENDRICKS PHARMACY	137 N HARVARD AVE	CLAREMONT	CA	91711	01/12/2017	04/01/2017		01/12/2017
Contract Detail	KROGER SPECIALTY PHARMACY CA 2	6240 WILSHIRE BLVD.		LOS ANGELES	CA	90048	10/10/2019	01/01/2020	12/14/2021	12/14/2021
Contract Detail	KROGER SPECIALTY PHARMACY INC	KROGER SPECIALTY PHARMACY CA 3	1821 KAISER AVE	IRVINE	CA	92614-5707	10/10/2019	01/01/2020	02/28/2022	03/07/2022
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	01/17/2017	04/01/2017	10/05/2020	10/09/2020
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	10/04/2022	01/01/2023		01/01/2023
Contract Detail	OPTUM INFUSION SERVICES 401, LLC	4610 NORTHGATE BLVD.	STE. 130	SACRAMENTO	CA	95834-1154	07/15/2021	07/26/2021		07/26/2021
Contract Detail	OPTUM INFUSION SERVICES 402, LLC	2300 MAIN ST STE 150		IRVINE	CA	92614-6223	07/15/2021	07/26/2021	08/16/2024	09/30/2024
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/15/2021	07/26/2021		07/26/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/07/2022	04/08/2022		04/11/2022
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	04/14/2025	07/01/2025		04/14/2025
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	01/17/2017	04/01/2017		01/17/2017
Contract Detail	OPTUM PHARMACY 704, INC.	5627 UNIVERSITY HTS STE 108		SAN ANTONIO	TX	78249	04/14/2025	07/01/2025		04/14/2025
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	01/17/2017	04/01/2017		01/17/2017
Contract Detail	OPTUM PHARMACY 706, INC.	30-30 47TH AVENUE	SUITE 410	LONG ISLAND CITY	NY	11101	01/17/2017	04/01/2017	07/15/2021	07/15/2021
Contract Detail	OPTUM PHARMACY 707, INC	4900 RIVERGRADE RD STE E110		IRWINDALE	CA	91706-1401	07/15/2021	07/26/2021		07/26/2021
Contract Detail	OPTUM PHARMACY 806, INC.	2288 AUBURN BLVD	STE. 102	SACRAMENTO	CA	95821-1618	07/14/2020	07/14/2020	07/15/2021	07/15/2021
Contract Detail	ORANGE GROVE PHARMACY	1770 N ORANGE GROVE AVE STE 100		POMONA	CA	91767-3027	12/10/2007	12/10/2007	08/16/2016	08/29/2016
Contract Detail	ORANGE GROVE PHARMACY	1770 N ORANGE GROVE AVE STE 100		POMONA	CA	91767-3027	01/12/2017	04/01/2017	05/17/2017	05/19/2017
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/10/2017	10/01/2017	12/13/2023	02/24/2025
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	07/15/2016	10/01/2016		08/29/2016
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/11/2021	01/01/2022		01/01/2022
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/11/2021	01/01/2022		01/01/2022
Contract Detail	RALPH'S GROCERY CO	DBA RALPHS STORE #136	2661 GREEN RIVER ROAD	CORONA	CA	92882	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #700	12201 HIGHLAND AVE	RANCHO CUCAMONGA	CA	91730	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #13	7369 MILLIKEN AVE	RANCHO CUCAMONGA	CA	91730	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #45	12660 LIMONITE AVE	CORONA	CA	92880	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #13	7369 MILLIKEN AVE	RANCHO CUCAMONGA	CA	91730	10/10/2019	01/01/2020	11/11/2024	11/11/2024
Contract Detail	RALPHS GROCERY CO	DBA RALPHS #700	12201 HIGHLAND AVE	RANCHO CUCAMONGA	CA	91730	10/10/2019	01/01/2020	11/11/2024	11/11/2024
Contract Detail	RALPHS GROCERY CO.	DBA: RALPHS #113	16225 SIERRA LAKES PARKWAY	FONTANA	CA	92336-1245	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	RALPHS GROCERY CO.	DBA: RALPHS #113	16225 SIERRA LAKES PARKWAY	FONTANA	CA	92336-1245	10/10/2019	01/01/2020	11/11/2024	11/11/2024
Contract Detail	ROYALTY PHARMACY	ROYALTY PHARMACY	1902 ROYALTY DR. STE 110	POMONA	CA	91767-3036	01/12/2017	04/01/2017	05/17/2017	05/19/2017
Contract Detail	THRIFTY PAYLESS INC.	RITE AID #5604	611 EAST HOLT AVENUE	POMONA	CA	91767	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5600	1050 NORTH MOUNTAIN AVENUE	ONTARIO	CA	91762	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5595	1480 FOOTHILL BOULEVARD	LA VERNE	CA	91750	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5587	8760 19TH STREET	RANCHO CUCAMONGA	CA	91701	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5579	12059 CENTRAL AVENUE	CHINO	CA	91710	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5602	1841 EAST 4TH STREET	ONTARIO	CA	91764	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5586	9650 BASELINE ROAD	RANCHO CUCAMONGA	CA	91701	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6338	2059 SOUTH GAREY AVENUE	POMONA	CA	91766	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5578	4200 CHINO HILLS PKWY STE 500	CHINO HILLS	CA	91709	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #6492	15890 SOQUEL CANYON PARKWAY	CHINO HILLS	CA	91709	01/04/2017	04/01/2017	07/03/2017	07/03/2017
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5696	11673 CHERRY AVENUE	FONTANA	CA	92337	10/16/2017	01/01/2018	07/06/2020	07/07/2020
Contract Detail	THRIFTY PAYLESS, INC.	RITE AID #5598	222 WEST G STREET	ONTARIO	CA	91762	10/16/2017	01/01/2018	07/01/2020	07/14/2020
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-1922	12549 FOOTHILL BLVD		RANCHO CUCAMONGA	CA	91739	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-1941	1950 AUTO CENTER DR		GLENDORA	CA	91740	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-1992	1540 WEST FOOTHILL BLVD		UPLAND	CA	91786	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-2288	80 RIO RANCHO RD		POMONA	CA	91766	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-2292	1275 NORTH AZUSA AVENUE		COVINA	CA	91722	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-3464	3943 GRAND AVENUE		CHINO	CA	91710	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-3796	1333 NORTH MOUNTAIN AVENUE		ONTARIO	CA	91762-1105	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-5691	1445 EAST FOOTHILL BLVD		UPLAND	CA	91786	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/14/2016	10/01/2016	03/14/2017	03/15/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04382	795 E. FOOTHILL	POMONA	CA	91767	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06438	12490 CENTRAL AVENUE	CHINO	CA	91710	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06061	1241 W FOOTHILL BLVD	UPLAND	CA	91786-3681	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07230	495 E HOLT AVE	POMONA	CA	91767-5539	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #10202	2245 S EUCLID AVE	ONTARIO	CA	91762	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05372	16108 FOOTHILL BOULEVARD	FONTANA	CA	92335	01/06/2017	04/01/2017	04/28/2017	05/01/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05478	6701 CARNELIAN ST	RANCHO CUCAMONGA	CA	91701	01/06/2017	04/01/2017	04/28/2017	05/01/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05652	6400 HAVEN AVE	RANCHO CUCAMONGA	CA	91737	01/06/2017	04/01/2017	04/28/2017	05/01/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06147	2950 S ARCHIBALD AVE	ONTARIO	CA	91761-7303	01/06/2017	04/01/2017	04/28/2017	05/01/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #11472	3320 CHINO HILLS PKWY	CHINO HILLS	CA	91709	01/06/2017	04/01/2017		01/06/2017
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15296	2262 MARKET ST	SAN FRANCISCO	CA	94114	10/16/2017	01/01/2018	12/31/2021	12/31/2021
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #03815	111 S MAIN ST	ORANGE	CA	92868	10/16/2017	01/01/2018		10/16/2017
Contract Detail	WALGREEN CO.	DBA: WALGREENS #15331	500 PARNASSUS AVENUE LEVEL J, ROOM MU-145	SAN FRANCISCO	CA	94143	10/16/2017	01/01/2018	12/14/2023	03/13/2024
Contract Detail	WALGREEN CO.	DBA WALGREENS SPECIALTY PHARMACY #15296	2262 MARKET ST	SAN FRANCISCO	CA	94114	10/16/2017	01/01/2018		10/16/2017
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/04/2017	01/01/2018	12/31/2021	12/31/2021
Contract Detail	WALGREENS MAIL SERVICE, LLC	WALGREENS MAIL SERVICE #03397	8350 S RIVER PARKWAY	TEMPE	AZ	85284	10/12/2017	01/01/2018	12/31/2021	12/31/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	ALLIANCERX WALGREENS PRIME #12314	9775 SW GEMINI DR, STE 1	BEAVERTON	OR	97008	07/14/2016	10/01/2016	10/12/2021	10/12/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/14/2016	10/01/2016		08/29/2016
Contract Detail	WALMART PHARMACY 10-3132	778 E. ARROW HWY.		POMONA	CA	91767	07/14/2016	10/01/2016	03/14/2017	03/15/2017

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH050231A	Child	DSH	POMONA VALLEY HOSPITAL MEDICAL CENTER	Pomona Valley Hospital Medical Center Cancer Care Center	1910 Royalty Drive	Pomona	CA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Delete	Change Request	Safecor Health 4060 Business Park Drive #B Columbus, OH 43204		2/25/2025 10:51 AM
Contacts	Authorizing Official	Update	Profile Change Request	Scafiddi, Darlene Executive Vice President of Patient Care Pomona valley hospital medical Center 9098659879	Scafiddi, Darlene Executive Vice President Chief Operating Officer Pomona Valley Hospital Medical Center 9098659879	12/18/2024 7:16 AM
Details	Last Recertification Date	Update	Recertification	8/25/2023 1:42:02 PM	8/27/2024 8:07:00 AM	8/27/2024 8:07 AM
Contacts	Authorizing Official	Update	Profile Change Request	Scafiddi, Darlene Executive Vice President of Patient Care Pomona Valley Hospital Medical Center 9096634015	Scafiddi, Darlene Executive Vice President of Patient Care Pomona valley hospital medical Center 9098659879	2/29/2024 2:50 PM
Contacts	Authorizing Official	Update	Profile Change Request	Scafiddi, Darlene Vice President of Nursing and Ancillary Services Pomona valley hospital meducal center 9098659879	Scafiddi, Darlene Executive Vice President of Patient Care Pomona Valley Hospital Medical Center 9096634015	2/29/2024 7:25 AM
Details	Last Recertification Date	Update	Recertification	9/9/2022 1:28:17 PM	8/25/2023 1:42:02 PM	8/25/2023 1:42 PM
Contacts	Primary Contact	Update	Change Request	Toogood, Corbin Director of Pharmacy Pomona Valley Hospital Medical Center 9098659500-3143	Hiroshige, Clifford Director of Pharmacy Pomona Valley Hospital Medical Center 9098659656	7/21/2023 8:29 AM
Contacts	Primary Contact	Update	Change Request	Campbell, Michael Director of Pharmacy Pomona Valley Hospital 9098659501	Toogood, Corbin Director of Pharmacy Pomona Valley Hospital Medical Center 9098659500-3143	1/9/2023 2:01 PM
Details	Last Recertification Date	Update	Recertification	8/24/2021 7:30:56 AM	9/9/2022 1:28:17 PM	9/9/2022 1:28 PM
Details	Last Recertification Date	Update	Recertification	9/7/2020 9:45:34 AM	8/24/2021 7:30:56 AM	8/24/2021 7:30 AM
Medicaid Billing	NPI: State	Update	Recertification		CA	9/7/2020 9:45 AM
Details	Last Recertification Date	Update	Recertification	9/4/2019 2:31:02 PM	9/7/2020 9:45:34 AM	9/7/2020 9:45 AM
Contacts	Authorizing Official	Update	Change Request	Nelson, Michael A.G. Vice President Pomona Valley Hospital Medical Center 9098659843	Scafiddi, Darlene Vice President of Nursing and Ancillary Services Pomona valley hospital meducal center 9098659879	10/25/2019 12:51 PM
Details	Last Recertification Date	Update	Recertification	9/10/2018 12:36:52 PM	9/4/2019 2:31:02 PM	9/4/2019 2:31 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 1:39:56 PM	9/10/2018 12:36:52 PM	9/10/2018 12:36 PM
Details	Last Recertification Date	Update	Recertification	8/15/2016 12:00:00 AM	11/29/2017 1:39:56 PM	11/29/2017 1:39 PM
Contacts	Primary Contact	Update	Profile Change Request	Campbell, Michael Directoe of Pharmacy Pomona Valley Hospital 9098659501	Campbell, Michael Director of Pharmacy Pomona Valley Hospital 9098659501	11/9/2017 12:35 PM
Contacts	Authorizing Official	Update		Nelson, Michael A.G. Vice President 9098659843	Nelson, Michael A.G. Vice President Pomona Valley Hospital Medical Center 9098659843	10/4/2017 11:32 AM
Contacts	Primary Contact	Update		Campbell, Michael Directoe of Pharmacy 9098659501	Campbell, Michael Directoe of Pharmacy Pomona Valley Hospital 9098659501	10/3/2017 11:08 AM
Addresses	Main Address	Insert			1798 NORTH GAREY AVENUE POMONA, CA 91767	7/12/2017 3:15 PM
Addresses	Shipping Address	Insert			Safecor Health 4060 Business Park Drive #B Columbus, OH 43204	7/12/2017 3:15 PM
Contacts	Primary Contact	Update		Le-Tran, Candice Director of Regulatory Reimbursement & Analytics 9098659844	Campbell, Michael Directoe of Pharmacy 9098659501	7/12/2017 3:15 PM
Contacts	Authorizing Official	Insert			Nelson, Michael A.G. Vice President 9098659843	7/12/2017 3:15 PM
Contacts	Primary Contact	Update		DOTTS, THOMAS D. DIRECTOR, PHARMACY SERVICES 9098659656	Le-Tran, Candice Director of Regulatory Reimbursement & Analytics 9098659844	8/31/2016 9:09 AM
Contacts	Primary Contact	Insert			DOTTS, THOMAS D. DIRECTOR, PHARMACY SERVICES 9098659656	8/25/2016 11:16 AM
Details	Last Recertification Date	Update		9/4/2015 12:00:00 AM	8/15/2016 12:00:00 AM	8/15/2016 6:56 PM
Medicaid Billing	NPI: Number	Insert			1407813660	7/12/2016 6:07 PM
Details	Last Recertification Date	Update		9/8/2014 12:00:00 AM	9/4/2015 12:00:00 AM	9/4/2015 5:33 PM
Details	Last Recertification Date	Update		9/10/2013 12:00:00 AM	9/8/2014 12:00:00 AM	9/8/2014 1:31 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/10/2013 12:00:00 AM	9/10/2013 6:28 PM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	5/25/2012 10:09 AM
Details	Last Recertification Date	Insert				11/28/2006 6:44 AM
Details	Grant Number	Insert				11/28/2006 6:44 AM
Details	340B ID	Insert			DSH050231	11/28/2006 6:44 AM
Details	Is Authorizing Official EHB Data	Insert				11/28/2006 6:44 AM
Dates	Last Date That 340B Drugs Purchased	Insert				11/28/2006 6:44 AM
Details	Medicare Provider Number	Insert			050231	11/28/2006 6:44 AM
Details	Entity Name	Insert			POMONA VALLEY HOSPITAL MEDICAL CENTER	11/28/2006 6:44 AM
Details	Program Code	Insert			DSH	11/28/2006 6:44 AM
Details	Entity Subname	Insert				11/28/2006 6:44 AM
Dates	Participating Approval Date	Insert			11/28/2006 12:00:00 AM	11/28/2006 6:44 AM
Details	State	Insert			Active	11/28/2006 6:44 AM
Dates	Registration Date	Insert			11/27/2006 12:00:00 AM	11/28/2006 6:44 AM
Dates	Signed By Date	Insert			11/20/2006 12:00:00 AM	11/28/2006 6:44 AM
Dates	Start Date	Insert			1/1/2007 12:00:00 AM	11/28/2006 6:44 AM
Terminations	Termination Comments	Insert				11/28/2006 6:44 AM
Terminations	Termination Date	Insert				11/28/2006 6:44 AM
Terminations	Termination Effective Date	Insert				11/28/2006 6:44 AM
Terminations	Termination Reason	Insert				11/28/2006 6:44 AM