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SAVE MART PHARMACY #103
DSH050568 MADERA COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MADERA COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050568
Entity Address
1250 E ALMOND AVENUE
MADERA, CA 93637
Medicare Provider Number
050568
Participating Start Date
4/1/2006
Last Recertification Date
8/25/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
SAVE MART PHARMACY #103
Pharmacy Address
1225 E. ROBERTSON BLVD.
CHOWCHILLA, CA 93610
Pharmacy Comments
Contract Details
Approval Date
7/7/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
MARK FOOTE, VP FINANCE/CFO
(559) 675-5505
Contract Pharmacy Representative
Robert Vaughan, Senior Director of Pharmacy Operations
(209) 574-6220
Signed By Date
7/7/2014
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