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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH520066 MERCY HEALTH SYSTEM CORPORATION
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Covered Entity Details
Entity Name
MERCY HEALTH SYSTEM CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520066
Entity Address
1000 MINERAL POINT AVE
JANESVILLE, WI 53547-5003
Medicare Provider Number
520066
Participating Start Date
4/1/2019
Last Recertification Date
8/30/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09233
515 S STATE HIGHWAY 49
JACKSON, CA 95642
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126
Contract Pharmacy Representative
CVS
Gabrielle Lagana, Implementation Consultant
(212) 419-4049
Signed By Date
4/9/2020
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