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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050300 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050300
Entity Address
18300 US HIGHWAY 18
APPLE VALLEY, CA 92307
Medicare Provider Number
050300
Participating Start Date
10/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04291
12058 PALMDALE RD
ADELANTO, CA 92301
Pharmacy Comments
Contract Details
Approval Date
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eugene Gutierrez, Chief Financial Officer
(760) 946-8105
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/7/2023
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