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WALMART PHARMACY 10-3147
DSH050159R VENTURA COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
VENTURA COUNTY MEDICAL CENTER
Subdivision Name
Orthopedic Clinic
Type
Disproportionate Share Hospital
340B ID
DSH050159R
Entity Address
300 HILLMONT AVE
Ventura, CA 93003
Medicare Provider Number
050159
Outpatient Facility Provider Number
Participating Start Date
1/1/1998
Last Recertification Date
8/31/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-3147
Pharmacy Address
2204 TAPO STREET
SIMI VALLEY, CA 93063
Pharmacy Comments
Contract Details
Approval Date
1/20/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kathleen Kellerhouse, Chief of Hospital Operations
(805) 652-6052
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/20/2015
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