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WAL-MART PHARMACY 10-2292
DSH050231 POMONA VALLEY HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
POMONA VALLEY HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050231
Entity Address
1798 NORTH GAREY AVENUE
POMONA, CA 91767
Medicare Provider Number
050231
Participating Start Date
1/1/2007
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2292
Pharmacy Address
1275 NORTH AZUSA AVENUE
COVINA, CA 91722
Pharmacy Comments
Contract Details
Approval Date
7/14/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/14/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
RICHARD YOCHUM, CEO
(909) 865-9500 Ext: 9975
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/14/2016
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