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THRIFTY PAYLESS, INC.
DSH050394 CMH OF SAN BUENAVENTURA
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Covered Entity Details
Entity Name
CMH OF SAN BUENAVENTURA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050394
Entity Address
147 N. BRENT STREET
VENTURA, CA 93003
Medicare Provider Number
050394
Participating Start Date
10/1/2019
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5772
2738 EAST THOMPSON BLVD.
VENTURA, CA 93003
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
DAVID BURRIS GLYER, cfo
(805) 652-5003
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/14/2019
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