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ALBERTSONS LLC
DSH050099 SAN ANTONIO REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
SAN ANTONIO REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050099
Entity Address
999 SAN BERNARDINO ROAD
UPLAND, CA 91786
Medicare Provider Number
050099
Participating Start Date
1/1/2018
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
ALBERTSONS LLC
Pharmacy Address
SAV-ON PHARMACY #3513
20261 HIGHWAY 18
APPLE VALLEY, CA 92307
Pharmacy Comments
Contract Details
Approval Date
1/8/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter Aprato, Compliance Officer
(909) 694-1098
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
1/8/2019
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