Contract Pharmacy Details

MILVIA OUTPATIENT PHARMACY
DSH050305B ALTA BATES SUMMIT MED - HERRICK (ABSM-H)

Covered Entity Details

Entity Name

ALTA BATES SUMMIT MED - HERRICK (ABSM-H)

Subdivision Name

COMPREHENSIVE CANCER CENTER

Type

Disproportionate Share Hospital

340B ID

DSH050305B

Entity Address

2001 DWIGHT WAY
room 1125
BERKELEY, CA 94704

Medicare Provider Number

050305

Outpatient Facility Provider Number

Participating Start Date

7/1/2006

Last Recertification Date

8/26/2014

Entity Termination Date

10/1/2015

Pharmacy Details

Pharmacy Name

MILVIA OUTPATIENT PHARMACY

Pharmacy Address

2001 DWIGHT WAY
1380D
BERKELEY, CA 94704-2608

Pharmacy Comments

Contract Details

Approval Date

7/2/2012

Contract Begin Date

7/2/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/13/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Charles J. Prosper, Chief Executive Officer
(510) 869-6199

Contract Pharmacy Representative

Charles J. Prosper, Chief Executive Officer
(510) 869-6199

Signed By Date

7/1/2012

340B Drug Pricing Program Database