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KROGER SPECIALTY PHARMACY FL 2
DSH050078 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050078
Entity Address
1300 W 7TH STREET
SAN PEDRO, CA 90732
Medicare Provider Number
050078
Participating Start Date
7/1/2005
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
KROGER SPECIALTY PHARMACY FL 2
Pharmacy Address
6435 HAZELTINE NATIONAL DR STE 140
ORLANDO, FL 32822-5156
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Ted Wang, CFO
(310) 303-6114
Contract Pharmacy Representative
Kroger
Katie Elfers, 340B Pharmacy Administrator
(513) 762-4850
Signed By Date
7/15/2019
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