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FORTIFY MARKET
DSH050103 WHITE MEMORIAL MEDICAL CENTER, DBA Adventist Health White Memorial
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Covered Entity Details
Entity Name
WHITE MEMORIAL MEDICAL CENTER, DBA Adventist Health White Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050103
Entity Address
1720 EAST CESAR E CHAVEZ AVENUE
LOS ANGELES, CA 90033
Medicare Provider Number
050103
Participating Start Date
7/1/2005
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
FORTIFY MARKET
Pharmacy Address
ONE ADVENTIST HEALTH WAY
ROSEVILLE, CA 95661
Pharmacy Comments
Contract Details
Approval Date
4/17/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Francis Christopher Owens, Finance Officer
(323) 268-5000 Ext: 14733
Contract Pharmacy Representative
Adventist Health
Mandy Kazminy, Pharmacy Manager
(916) 406-0188
Signed By Date
4/17/2025
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