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ST JOSEPH'S MCAULEY PHARMACY
CAH051332-00 Mark Twain Medical Center
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Covered Entity Details
Entity Name
Mark Twain Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051332-00
Entity Address
768 Mountain Ranch Road
San Andreas, CA 95249
Medicare Provider Number
051332
Participating Start Date
4/1/2013
Last Recertification Date
8/14/2024
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
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Larry Philipp, CEO
(209) 754-2515
Contract Pharmacy Representative
St. Joseph's Hospital and Medical Center
Greg Blank, Director of Pharmacy
(602) 406-4744
Signed By Date
4/15/2019
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