340B Drug Pricing Program Database
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CAH051317-09 Adventist Health Clearlake Hospital, Inc. (Active)
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Main Details
Name
Adventist Health Clearlake Hospital, Inc.
Subdivision Name
Konocti Wellness Center / Konocti Clinic
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH051317-09
Medicare Provider Number
051317
Outpatient Facility Provider Number
058681
Additional Details
Current Program Status
Active
Registration Date
10/14/2016
Participating Start Date
1/1/2017
Participating Approval Date
10/28/2016
Last Recertification Date
8/18/2024
Contacts
Authorizing Official
Adventist Health North Coast Network
Jeff Mock, Finance Officer, North Coast Network
(916) 406-1417
Primary Contact
St Helena Hospital Clearlake
Jacarre Shelton, Director of Pharmacy
(707) 995-5800
Addresses
Street Address
9430 Lake Street
Building C
Lower Lake, CA 95457
Billing Address
Adventist Health Clear Lake
15630 18th Avenue
Clearlake, CA 95422
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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