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RALEY'S PHARMACY #422
DSH050254 MARSHALL HOSPITAL
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Covered Entity Details
Entity Name
MARSHALL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050254
Entity Address
1100 MARSHALL WAY
PLACERVILLE, CA 95667
Medicare Provider Number
050254
Participating Start Date
1/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
RALEY'S PHARMACY #422
Pharmacy Address
166 PLACERVILLE DR
PLACERVILLE, CA 95667
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/9/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
James Whipple, Chief Executive Officer
(530) 626-2601
Contract Pharmacy Representative
Raley's Pharmacy
David Fluitt, Director of Pharmacy Operations
(916) 373-6146
Signed By Date
7/12/2019
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