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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050336 Adventist Health Lodi Memorial
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Covered Entity Details
Entity Name
Adventist Health Lodi Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050336
Entity Address
975 S. FAIRMONT AVENUE
LODI, CA 95240
Medicare Provider Number
050336
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09147
2605 WEST MARCH LANE
STOCKTON, CA 95207
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Whitney, Finance Officer
(209) 339-7477
Contract Pharmacy Representative
Adventist Health Lodi Memorial
Sandy Beck Atwater, Pharmacy Director
(209) 339-7555
Signed By Date
10/15/2018
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