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MISSION MEDICAL PHARMACY
DSH050567 MISSION HOSPITAL
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Covered Entity Details
Entity Name
MISSION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050567
Entity Address
27700 Medical Center Road
Mission Viejo, CA 92691
Medicare Provider Number
050567
Participating Start Date
4/1/2016
Last Recertification Date
8/29/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
MISSION MEDICAL PHARMACY
Pharmacy Address
27800 MEDICAL CENTER RD
#99
MISSION VIEJO, CA 92691
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eileen Haubl, Chief Financial Officer
(949) 364-1400 Ext: 5408
Contract Pharmacy Representative
Advantage HealthCare Services
Vimal Bhanvadia, owner
(949) 364-0122
Signed By Date
7/17/2017
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