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SAN ANTONIO PHARMACY
DSH050099 SAN ANTONIO REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
SAN ANTONIO REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050099
Entity Address
999 SAN BERNARDINO ROAD
UPLAND, CA 91786
Medicare Provider Number
050099
Participating Start Date
1/1/2018
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
SAN ANTONIO PHARMACY
Pharmacy Address
255 E BONITA AVE BLDG 1 SUITE 102
POMONA, CA 91767-1923
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Peter Aprato, Compliance Officer
(909) 694-1098
Contract Pharmacy Representative
San Antonio Regional Hospital
Dennis Ancheta, Director of Pharmacy
(909) 920-4849 Ext: 24849
Signed By Date
1/10/2020
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