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WAL-MART PHARMACY 10-2001
DSH050060 COMMUNITY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COMMUNITY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050060
Entity Address
2823 FRESNO STREET
FRESNO, CA 93721
Medicare Provider Number
050060
Participating Start Date
4/1/2007
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2001
Pharmacy Address
5125 EAST KINGS CANYON
FRESNO, CA 93727
Pharmacy Comments
Contract Details
Approval Date
7/10/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/18/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOSEPH M. NOWICKI, CFO
(559) 324-4780
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/10/2014
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