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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050078 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER SAN PEDRO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050078
Entity Address
1300 W 7TH STREET
SAN PEDRO, CA 90732
Medicare Provider Number
050078
Participating Start Date
7/1/2005
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09513
1570 ROSECRANS AVE
MANHATTAN BEACH, CA 90266
Pharmacy Comments
Contract Details
Approval Date
1/18/2021
Contract Begin Date
1/21/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Fleming Goeders, Chief Financial Officer
(310) 829-8411
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/18/2021
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