Contract Pharmacy Details

FOX DRUG STORE
DSH050196 Central Valley General Hospital

Covered Entity Details

Entity Name

Central Valley General Hospital

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050196

Entity Address

1025 N. Douty Street
Hanford, CA 93230

Medicare Provider Number

050196

Participating Start Date

1/1/2008

Last Recertification Date

8/17/2016

Entity Termination Date

10/1/2016

Pharmacy Details

Pharmacy Name

FOX DRUG STORE

Pharmacy Address

1939 HIGH ST
SELMA, CA 93662-3510

Pharmacy Comments

Contract Details

Approval Date

10/11/2012

Contract Begin Date

10/11/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2016

Contacts

Covered Entity Signing Official

David L. Larsen, Senior VP & CFO
(559) 537-0053

Contract Pharmacy Representative

Sunnyside Pharmacy
Lunny Jung, CEO
(213) 590-2375

Signed By Date

9/17/2012