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DBA: QUEENS PHARMACY
DSH050300 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050300
Entity Address
18300 US HIGHWAY 18
APPLE VALLEY, CA 92307
Medicare Provider Number
050300
Participating Start Date
10/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
DBA: QUEENS PHARMACY
Pharmacy Address
ASR HEALTH INC
18522 US HIGHWAY 18
STE 103
APPLE VALLEY, CA 92307
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
1/21/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eugene Gutierrez, Chief Financial Officer
(760) 946-8105
Contract Pharmacy Representative
Queens Pharmacy
Srinivasa Kandru, Director
(760) 946-4700
Signed By Date
1/15/2021
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