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WAL-MART PHARMACY 10-2044
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
WAL-MART PHARMACY 10-2044
Pharmacy Address
2044 FOREST AVENUE
CHICO, CA 95928
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CARLTON Edward JACOBSON, CFO
(707) 995-5824
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2021
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