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GARFIELD BEACH CVS, L.L.C.
DSH050235 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE SAINT JOSEPH MEDICAL CENTER
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE SAINT JOSEPH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050235
Entity Address
501 S BUENA VISTA STREET
BURBANK, CA 91505
Medicare Provider Number
050235
Participating Start Date
7/1/2005
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
GARFIELD BEACH CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09795
511 N. HOLLYWOOD WAY
BURBANK, CA 91505
Pharmacy Comments
Contract Details
Approval Date
4/10/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Glenn Bales, Chief Financial Officer
(818) 847-3022
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/10/2023
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