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NORTH LAKE MEDICAL PHARMACY #2
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
NORTH LAKE MEDICAL PHARMACY #2
Pharmacy Address
347 LAKEPORT BLVD
LAKEPORT, CA 95453
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
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
North Lake Pharmacy, Inc
Neeley Danny, Owner
(707) 263-1328
Signed By Date
7/15/2020
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