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IVANHOE PHARMACY
DSH050057 Kaweah Delta Health Care District DBA Kaweah Health
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Covered Entity Details
Entity Name
Kaweah Delta Health Care District DBA Kaweah Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050057
Entity Address
400 West Mineral King Avenue
Visalia, CA 93291
Medicare Provider Number
050057
Participating Start Date
7/1/2004
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
IVANHOE PHARMACY
Pharmacy Address
33060 RD 159
IVANHOE, CA 93235-1235
Pharmacy Comments
Contract Details
Approval Date
4/28/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
GARY K. HERBST, Chief Executive Officer
(559) 624-2330
Contract Pharmacy Representative
Ed Derderian, Owner
(559) 798-1219
Signed By Date
4/28/2015
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