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WAL-MART PHARMACY 10-1903
DSH050133 RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
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Covered Entity Details
Entity Name
RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050133
Entity Address
726 4TH STREET
MARYSVILLE, CA 95901
Medicare Provider Number
050133
Participating Start Date
7/2/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1903
Pharmacy Address
1150 HARTER ROAD
YUBA CITY, CA 95993
Pharmacy Comments
Contract Details
Approval Date
7/4/2018
Contract Begin Date
7/2/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ed Gonzalez, CFO
(530) 751-4010
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, VP of Health and Wellness Transformation
(479) 204-9374
Signed By Date
7/4/2018
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