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INFUSION CARE PHARMACY NORTH
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
INFUSION CARE PHARMACY NORTH
Pharmacy Address
455 E COLUMBIA ST
SUITE 10
LONG BEACH, CA 90806
Pharmacy Comments
Contract Details
Approval Date
1/12/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/13/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Bishop, Chief Executive Officer
(562) 933-1111
Contract Pharmacy Representative
Scott Preston, Director of Pharmacy
(562) 933-0328
Signed By Date
1/12/2015
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