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DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
SCH270051-00 KALISPELL REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
KALISPELL REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH270051-00
Entity Address
310 SUNNYVIEW LANE
KALISPELL, MT 59901
Medicare Provider Number
270051
Participating Start Date
9/24/2010
Last Recertification Date
9/11/2020
Entity Termination Date
1/1/2021
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
Pharmacy Address
DIPLOMAT SPECIALTY PHARMACY
1809 EXCISE AVENUE
SUITE 204-208
ONTARIO, CA 91761
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
CHARLES PEARCE, C.F.I.O.
(406) 752-1724
Contract Pharmacy Representative
Diplomat
Sandra Barbosa, Pharmacy Manager
(602) 366-4692
Signed By Date
1/17/2017
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