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THRIFTY PAYLESS, INC.
DSH050278 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE HOLY CROSS MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE HOLY CROSS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050278
Entity Address
15031 RINALDI STREET
MISSION HILLS, CA 91345
Medicare Provider Number
050278
Participating Start Date
7/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5553
10823 ZELZAH AVENUE BLDG D
GRANADA HILLS, CA 91344
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
10/15/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia Ann Mayberry, COO
(818) 496-4790
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
7/15/2019
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