Contract Pharmacy Details

FOX DRUG STORE
DSH050121 Adventist Medical Center

Covered Entity Details

Entity Name

Adventist Medical Center

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050121

Entity Address

115 mall drive
HANFORD, CA 93230

Medicare Provider Number

050121

Participating Start Date

1/1/2008

Last Recertification Date

9/6/2024

Pharmacy Details

Pharmacy Name

FOX DRUG STORE

Pharmacy Address

1939 HIGH ST
SELMA, CA 93662-3510

Pharmacy Comments

Contract Details

Approval Date

8/17/2012

Contract Begin Date

8/17/2012

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

David L. Larsen, SR VP CFO
(559) 537-0050

Contract Pharmacy Representative

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

Signed By Date

7/24/2012