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THRIFTY PAYLESS, INC.
DSH050054 SAN GORGONIO MEMORIAL
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Covered Entity Details
Entity Name
SAN GORGONIO MEMORIAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050054
Entity Address
600 NORTH HIGHLAND SPRINGS AVE
BANNING, CA 92220
Medicare Provider Number
050054
Participating Start Date
7/1/2023
Last Recertification Date
8/27/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5672
806 W RAMSEY STREET
BANNING, CA 92220
Pharmacy Comments
Contract Details
Approval Date
5/1/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
daniel heckathorne, CFO
(951) 769-2103
Contract Pharmacy Representative
San Gorgonio Memorial Hospital
Jose A Lopez, Pharmacy Director
(951) 769-4805
Signed By Date
4/17/2023
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