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PROCARE PHARMACY, L.L.C.
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
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY OR CARELONRX SPECIALTY
ONE WATERFRONT PLAZA
500 ALA MOANA BLVD., BLDG 1
HONOLULU, HI 96813
Pharmacy Comments
3/22/10 NAME CORRECTION (WAS CVS PROCARE PHARMACY DBA CVS PROCARE PHARMACY #2915) 3/17/10 ADDR CHANGE (WAS 970 N KALAHEO AVE, SUITE A 203)
Contract Details
Approval Date
8/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ted Wang, CFO
(310) 303-6114
Contract Pharmacy Representative
Advanced Care Scripts
Jason Kwasigroch, Pharmacist in Charge
(877) 985-6337
Signed By Date
8/11/2017
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