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WAL-MART PHARMACY 10-2277
DSH050492 Fresno Community Hospital & Medical Center dba Clovis Community Medical Center
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Covered Entity Details
Entity Name
Fresno Community Hospital & Medical Center dba Clovis Community Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050492
Entity Address
2755 Herndon Avenue
Clovis, CA 93611
Medicare Provider Number
050492
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2277
Pharmacy Address
323 WEST SHAW AVE
CLOVIS, CA 93612
Pharmacy Comments
Contract Details
Approval Date
7/15/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/18/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tracy Kiritani, VP Hospital Financial Operations
(559) 324-4844
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/15/2014
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