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KROGER SPECIALTY PHARMACY CA 2
DSH050231 POMONA VALLEY HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
POMONA VALLEY HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050231
Entity Address
1798 NORTH GAREY AVENUE
POMONA, CA 91767
Medicare Provider Number
050231
Participating Start Date
1/1/2007
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
KROGER SPECIALTY PHARMACY CA 2
Pharmacy Address
6240 WILSHIRE BLVD.
LOS ANGELES, CA 90048
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/14/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Michael A.G. Nelson, Vice President
(909) 865-9843
Contract Pharmacy Representative
Pomona Valley Hospital
Michael Campbell, Director of Pharmacy
(909) 865-9501
Signed By Date
10/10/2019
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