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LONGS DRUG STORES CALIFORNIA, L.L.C.
CAH051317-00 Adventist Health Clearlake Hospital, Inc.
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Covered Entity Details
Entity Name
Adventist Health Clearlake Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051317-00
Entity Address
15630 18th Ave - Hwy 53
Clearlake, CA 95422
Medicare Provider Number
051317
Participating Start Date
10/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 07128
2780 ESPLANADE
CHICO, CA 95973
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CARLTON Edward JACOBSON, CFO
(707) 995-5824
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/13/2020
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