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LONGS DRUG STORES CALIFORNIA, L.L.C.
CAH051328-00 TAHOE FOREST HOSPITAL
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Covered Entity Details
Entity Name
TAHOE FOREST HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051328-00
Entity Address
10121 PINE AVENUE
TRUCKEE, CA 96161
Medicare Provider Number
051328
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09174
11411 DEERFIELD DR
TRUCKEE, CA 96161
Pharmacy Comments
Contract Details
Approval Date
4/3/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CRYSTAL BETTS, CHIEF FINANCIAL OFFICER
(530) 582-6656
Contract Pharmacy Representative
Tahoe Forest Hospital District
Anthony Scott Cooper, Director of Pharmacy
(530) 582-6465
Signed By Date
4/3/2019
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