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THE VONS COMPANIES INC
DSH050300 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050300
Entity Address
18300 US HIGHWAY 18
APPLE VALLEY, CA 92307
Medicare Provider Number
050300
Participating Start Date
10/1/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
THE VONS COMPANIES INC
Pharmacy Address
VONS PHARMACY #2376
1270 EAST MAIN STREET
BARSTOW, CA 92311
Pharmacy Comments
Contract Details
Approval Date
10/8/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
Tracey Fernandez, VP /CFO
(760) 242-2311 Ext: 8727
Contract Pharmacy Representative
Masina Berry, 340B Analyst
(208) 395-3860
Signed By Date
10/8/2015
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