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THRIFTY PAYLESS, INC.
DSH050369 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS
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Covered Entity Details
Entity Name
CITRUS VALLEY MEDICAL CENTER - QV CAMPUS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050369
Entity Address
1115 S SUNSET AVE
WEST COVINA, CA 91790
Medicare Provider Number
050369
Participating Start Date
4/1/2006
Last Recertification Date
9/9/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5610
1528 EAST AMAR ROAD
WEST COVINA, CA 91792
Pharmacy Comments
Contract Details
Approval Date
1/3/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Rajesh Sharma, CFO
(626) 938-7595
Contract Pharmacy Representative
Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217
Signed By Date
1/3/2014
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