Contract Pharmacy Details

PARK REXALL PHARMACY
DSH050079 DOCTORS MEDICAL CENTER

Covered Entity Details

Entity Name

DOCTORS MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050079

Entity Address

2000 VALE ROAD
SAN PABLO, CA 94806

Medicare Provider Number

050079

Participating Start Date

1/1/2007

Last Recertification Date

9/3/2014

Entity Termination Date

4/24/2015

Pharmacy Details

Pharmacy Name

PARK REXALL PHARMACY

Pharmacy Address

3716 SAN PABLO DAM ROAD
EL SOBRANTE, CA 94803

Pharmacy Comments

Contract Details

Approval Date

7/16/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/24/2015
Covered Entity Terminated

Contacts

Covered Entity Signing Official

JAMES BOATMAN, CFO
(510) 970-5024

Contract Pharmacy Representative

David Jeha, Pharmacist
(510) 223-1321

Signed By Date

7/16/2013