Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050568 MADERA COMMUNITY HOSPITAL

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

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 09159
1109 COUNTRY CLUB DR
MADERA, CA 93638

Pharmacy Comments

Contract Details

Approval Date

7/17/2017

Contract Begin Date

10/1/2017

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

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/17/2017

340B Drug Pricing Program Database