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NOB HILL PHARMACY #605
DSH050296 HAZEL HAWKINS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
HAZEL HAWKINS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050296
Entity Address
911 SUNSET DRIVE
HOLLISTER, CA 95023
Medicare Provider Number
050296
Participating Start Date
4/1/2018
Last Recertification Date
8/26/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
NOB HILL PHARMACY #605
Pharmacy Address
1700 AIRLINE HIGHWAY
HOLLISTER, CA 95023
Pharmacy Comments
Contract Details
Approval Date
7/13/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
MARK ROBINSON, CFO
(831) 636-2604
Contract Pharmacy Representative
Raley's
Alisha Reynoso, Pharmacy Operations
(916) 376-6687
Signed By Date
7/13/2018
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