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THRIFTY PAYLESS, INC.
DSH050231 POMONA VALLEY HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
POMONA VALLEY HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050231
Entity Address
1798 NORTH GAREY AVENUE
POMONA, CA 91767
Medicare Provider Number
050231
Participating Start Date
1/1/2007
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #5696
11673 CHERRY AVENUE
FONTANA, CA 92337
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael A.G. Nelson, Vice President
(909) 865-9843
Contract Pharmacy Representative
CaptureRx
Mike Puccini, Business Dev. Mgr.
(513) 762-4693
Signed By Date
10/16/2017
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