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GREEN'S FORTUNA PHARMACY
DSH050006 St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital
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Covered Entity Details
Entity Name
St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050006
Entity Address
2700 DOLBEER STREET
EUREKA, CA 95501
Medicare Provider Number
050006
Participating Start Date
4/1/2009
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
GREEN'S FORTUNA PHARMACY
Pharmacy Address
1058 MAIN ST
FORTUNA, CA 95540
Pharmacy Comments
Contract Details
Approval Date
1/25/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Patti Pilgrim, Regional CFO
(707) 525-5323
Contract Pharmacy Representative
Green's Fortuna Pharmacy
Robert Johnson, President
(707) 499-2336
Signed By Date
1/25/2021
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