Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050093 SAINT AGNES MEDICAL CENTER

Covered Entity Details

Entity Name

SAINT AGNES MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH050093

Entity Address

1303 E HERNDON AVE
FRESNO, CA 93720

Medicare Provider Number

050093

Participating Start Date

1/1/2014

Last Recertification Date

8/20/2024

Pharmacy Details

Pharmacy Name

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 09994
728 W SHAW AVE
FRESNO, CA 93704

Pharmacy Comments

Contract Details

Approval Date

10/14/2015

Contract Begin Date

1/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/1/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

NANCY HOLLINGSWORTH, CEO
(559) 450-3301

Contract Pharmacy Representative

CVS
Christian Reid, 340B Program Director, CVS Pharmacy
(401) 770-2118

Signed By Date

10/14/2015

340B Drug Pricing Program Database