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KMART PHARMACY #4705
DSH050121 Adventist Medical Center
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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
KMART PHARMACY #4705
Pharmacy Address
333 SIERRA
KINGSBURG, CA 93631
Pharmacy Comments
Contract Details
Approval Date
10/11/2012
Contract Begin Date
10/11/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David L. Larsen, SR VP CFO
(559) 537-0050
Contract Pharmacy Representative
Ghassan Hourani, VP/GMM Pharmacy Administration
(847) 286-3382
Signed By Date
9/14/2012
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