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ST JOSEPH'S MCAULEY PHARMACY
DSH050150 SIERRA NEVADA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SIERRA NEVADA MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050150
Entity Address
155 GLASSON WAY
GRASS VALLEY, CA 95945
Medicare Provider Number
050150
Participating Start Date
7/1/2016
Last Recertification Date
Pharmacy Details
Pharmacy Name
ST JOSEPH'S MCAULEY PHARMACY
Pharmacy Address
500 W. THOMAS ROAD
SUITE 190
PHOENIX, AZ 85013
Pharmacy Comments
Contract Details
Approval Date
4/5/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/21/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Hall, VP and CFO
(530) 274-6099
Contract Pharmacy Representative
St. Joseph's Hospital and Medical Center
Greg Blank, Director of Pharmacy
(602) 406-4744
Signed By Date
4/5/2019
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