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DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
DSH050353 PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
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Covered Entity Details
Entity Name
PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050353
Entity Address
4101 TORRANCE BLVD.
TORRANCE, CA 90503
Medicare Provider Number
050353
Participating Start Date
4/1/2007
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
1809 EXCISE AVENUE
SUITE 204-208
ONTARIO, CA 91761
Pharmacy Comments
Contract Details
Approval Date
7/16/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Ted Wang, CFO
(310) 303-6114
Contract Pharmacy Representative
Diplomat
Sandra Barbosa, Pharmacy Manager
(602) 366-4692
Signed By Date
7/16/2017
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