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LONGS DRUG STORES CALIFORNIA, L.L.C.
RRC120026-00 PALI MOMI MEDICAL CENTER
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Covered Entity Details
Entity Name
PALI MOMI MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC120026-00
Entity Address
98-1079 MOANALUA ROAD
AIEA, HI 96701
Medicare Provider Number
120026
Participating Start Date
11/9/2020
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: LONGS DRUGS # 09954
2470 S. KING ST.
HONOLULU, HI 96826
Pharmacy Comments
Contract Details
Approval Date
1/12/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David E Stumbaugh, VP, Supply Chain Management and Pharmacy
(808) 522-6946
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/12/2022
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