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MADERA MEDICAL PHARMACY
DSH050568 MADERA COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MADERA COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050568
Entity Address
1250 E ALMOND AVENUE
MADERA, CA 93637
Medicare Provider Number
050568
Participating Start Date
4/1/2006
Last Recertification Date
8/25/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
MADERA MEDICAL PHARMACY
Pharmacy Address
LBN- MEL PHARM INC
402 S. MADERA AVENUE
SUITE A
MADERA, CA 93637
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
MARK FOOTE, VP FINANCE/CFO
(559) 675-5505
Contract Pharmacy Representative
Mel-Pharm Inc.
Sirtaj Singh, President/Owner
(559) 674-8553
Signed By Date
10/12/2020
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