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STONE SOUP ENTERPRISES, INC.
PED053309-00 Long Beach Memorial Medical Center, Inc., dba MemorialCare Miller Children's and Women's Hospital Long Beach
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Covered Entity Details
Entity Name
Long Beach Memorial Medical Center, Inc., dba MemorialCare Miller Children's and Women's Hospital Long Beach
Subdivision Name
Type
Children's Hospital
340B ID
PED053309-00
Entity Address
2801 Atlantic Avenue 1st FL B1A3020
Long Beach, CA 90806-1428
Medicare Provider Number
053309
Participating Start Date
4/1/2013
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
STONE SOUP ENTERPRISES, INC.
Pharmacy Address
18009 SKYPARK CIRCLE, STE G
IRVINE, CA 92614
Pharmacy Comments
Contract Details
Approval Date
1/14/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/4/2015
Ownership change
Contacts
Covered Entity Signing Official
John Bishop, Chief Executive Officer
(562) 933-1111
Contract Pharmacy Representative
MICHAEL TRONT, PRESIDENT
(949) 476-6361
Signed By Date
1/14/2014
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