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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050129 ST. BERNARDINE MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. BERNARDINE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050129
Entity Address
2101 N. WATERMAN AVENUE
SAN BERNARDINO, CA 92404
Medicare Provider Number
050129
Participating Start Date
10/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09341
1540 E HIGHLAND AVE
SAN BERNARDINO, CA 92404
Pharmacy Comments
Contract Details
Approval Date
4/9/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DARRYL VANDENBOSCH, CHIEF FINANCIAL OFFICER
(909) 881-7196
Contract Pharmacy Representative
John R. Zevzavadjian, Vice President, Managed Care
(401) 770-5503
Signed By Date
4/9/2013
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