340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
CREEKSIDE PHARMACY
DSH050174 ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Print
Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050174
Entity Address
1165 MONTGOMERY DRIVE
Santa Rosa, CA 95405
Medicare Provider Number
050174
Participating Start Date
4/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CREEKSIDE PHARMACY
Pharmacy Address
95 MONTGOMERY DRIVE
SUITE 108
SANTA ROSA, CA 95404
Pharmacy Comments
Contract Details
Approval Date
4/24/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Raju Iyer, Regional CFO
(707) 806-8781
Contract Pharmacy Representative
Creekside Pharmacy
Tony Ibrahim, CEO/Owner
(707) 525-1130
Signed By Date
4/24/2018
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session