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WALGREEN CO.
DSH050089 COMMUNITY HOSPITAL OF SAN BERNARDINO
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF SAN BERNARDINO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050089
Entity Address
1805 MEDICAL CENTER DRIVE
SAN BERNARDINO, CA 92411
Medicare Provider Number
050089
Participating Start Date
10/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #12547
2011 N RIVERSIDE AVE
RIALTO, CA 92377
Pharmacy Comments
Contract Details
Approval Date
7/17/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/5/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DARRYL VANDENBOSCH, CHIEF FINANCIAL OFFICER
(909) 881-7196
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/17/2013
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