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THRIFTY PAYLESS, INC.
DSH050636 PALOMAR MEDICAL CENTER POWAY (PMC Poway)
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Covered Entity Details
Entity Name
PALOMAR MEDICAL CENTER POWAY (PMC Poway)
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050636
Entity Address
15615 POMERADO RD
POWAY, CA 92064-2405
Medicare Provider Number
050636
Participating Start Date
7/1/2015
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #6225
1665 ALPINE BOULEVARD
ALPINE, CA 91901
Pharmacy Comments
Contract Details
Approval Date
7/27/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/14/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane Lynette Hansen, President & CEO
(760) 740-6395
Contract Pharmacy Representative
PDS I Michigan, Inc
Allison Farrell, Senior Vice President
(717) 214-8834
Signed By Date
7/27/2017
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