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ST JOSEPH'S MCAULEY PHARMACY
CAH051319-00 DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA
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Covered Entity Details
Entity Name
DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051319-00
Entity Address
914 PINE STREET.
MOUNT SHASTA, CA 96067
Medicare Provider Number
051319
Participating Start Date
9/8/2010
Last Recertification Date
8/15/2024
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
4/11/2019
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
Kim Miranda, CFO
(916) 453-4459
Contract Pharmacy Representative
St. Joseph's Hospital and Medical Center
Greg Blank, Director of Pharmacy
(602) 406-4744
Signed By Date
4/11/2019
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