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MENDOCINO VILLAGE PHARMACY
CAH051325-00 ADVENTIST HEALTH MENDOCINO COAST
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Covered Entity Details
Entity Name
ADVENTIST HEALTH MENDOCINO COAST
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051325-00
Entity Address
700 RIVER DRIVE
FORT BRAGG, CA 95437
Medicare Provider Number
051325
Participating Start Date
8/11/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MENDOCINO VILLAGE PHARMACY
Pharmacy Address
10501 LANSING STREET
PO BOX 904
MENDOCINO, CA 95460
Pharmacy Comments
Contract Details
Approval Date
7/17/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Wayne C. Allen, CEO
(707) 961-4630
Contract Pharmacy Representative
Mendocino Village Pharmacy
Kelly Brodetsky, Owner
(707) 962-0800
Signed By Date
7/17/2019
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