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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH120005 HILO MEDICAL CENTER
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Covered Entity Details
Entity Name
HILO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH120005
Entity Address
1190 WAIANUENUE AVENUE
HILO, HI 96720-2020
Medicare Provider Number
120005
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: LONGS DRUGS # 01904
82 PUUHONU PLACE #103
HILO, HI 96720
Pharmacy Comments
Contract Details
Approval Date
1/21/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Dan Brinkman, CEO
(808) 932-3101
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/21/2021
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