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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050107 MARIAN MEDICAL CENTER
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Covered Entity Details
Entity Name
MARIAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050107
Entity Address
1400 E CHURCH ST
SANTA MARIA, CA 93454
Medicare Provider Number
050107
Participating Start Date
1/1/2005
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03153
733 E MAIN ST
SANTA MARIA, CA 93454
Pharmacy Comments
Contract Details
Approval Date
4/5/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SUE ANDERSEN, CFO
(805) 739-3110
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
4/5/2013
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