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CREEKSIDE PHARMACY
DSH050174 ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
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Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050174
Entity Address
1165 MONTGOMERY DRIVE
Santa Rosa, CA 95405
Medicare Provider Number
050174
Participating Start Date
4/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CREEKSIDE PHARMACY
Pharmacy Address
95 MONTGOMERY DR.
STE. 108
SANTA ROSA, CA 95404
Pharmacy Comments
Contract Details
Approval Date
1/8/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/5/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Klockenga, CEO
(707) 522-1520
Contract Pharmacy Representative
Creekside Pharmacy
Tony Ibrahim, CEO/Owner
(707) 525-1130
Signed By Date
1/8/2020
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