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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050254 MARSHALL HOSPITAL
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Covered Entity Details
Entity Name
MARSHALL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050254
Entity Address
1100 MARSHALL WAY
PLACERVILLE, CA 95667
Medicare Provider Number
050254
Participating Start Date
1/1/2016
Last Recertification Date
8/12/2024
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
10/7/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Siri Nelson, CEO
(707) 349-8127
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/7/2020
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