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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #03815
111 S MAIN ST
ORANGE, CA 92868
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael A.G. Nelson, Vice President
(909) 865-9843
Contract Pharmacy Representative
Walgreens
Rishabh Dave, 340B Operations Analyst
(847) 964-8379
Signed By Date
10/16/2017
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