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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
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
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
7/10/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/13/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Michael A.G. Nelson, Vice President
(909) 865-9843
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/10/2017
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