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CABRILLO PHARMACY
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
CABRILLO PHARMACY
Pharmacy Address
146 N. BRENT ST.
VENTURA, CA 93003
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID BURRIS GLYER, cfo
(805) 652-5003
Contract Pharmacy Representative
Cabrillo Pharmacy
Robert Leark, CEO
(805) 643-9939
Signed By Date
10/16/2019
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