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KROGER SPECIALTY PHARMACY CA 2
DSH050360 MARIN GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MARIN GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050360
Entity Address
250 BON AIR ROAD
GREENBRAE, CA 94904
Medicare Provider Number
050360
Participating Start Date
7/1/2016
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
KROGER SPECIALTY PHARMACY CA 2
Pharmacy Address
6240 WILSHIRE BLVD.
LOS ANGELES, CA 90048
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James McManus, Chief Financial Officer
(415) 925-2095
Contract Pharmacy Representative
Marin General Hospital
Therese Helser, Director, Pharmacy
(415) 925-7867
Signed By Date
1/11/2019
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