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WAL-MART PHARMACY 10-1756
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
WAL-MART PHARMACY 10-1756
Pharmacy Address
17251 FOOTHILL BLVD
FONTANA, CA 92335
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter Aprato, Compliance Officer
(909) 694-1098
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2021
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