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RALEY'S PHARMACY #332
DSH050367 NorthBay Healthcare Group
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Covered Entity Details
Entity Name
NorthBay Healthcare Group
Subdivision Name
NORTH BAY MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH050367
Entity Address
1200 B GALE WILSON BLVD
FAIRFIELD, CA 94533
Medicare Provider Number
050367
Participating Start Date
7/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
RALEY'S PHARMACY #332
Pharmacy Address
3001 TRAVIS BLVD.
FAIRFIELD, CA 94534
Pharmacy Comments
2/23/11 UPDATED NAME AND ZIP (WAS RALEY'S CORPORATION, 94533)
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Eichenberger, Senior Director, Revenue Cycle
(707) 646-3401
Contract Pharmacy Representative
340B Direct
McKinnlee Bowman, Executive Account Director
(801) 287-9110
Signed By Date
1/13/2020
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