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WAL-MART PHARMACY 10-1704
DSH050367 NorthBay Healthcare Group
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Covered Entity Details
Entity Name
NorthBay Healthcare Group
Subdivision Name
NORTH BAY MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH050367
Entity Address
1200 B GALE WILSON BLVD
FAIRFIELD, CA 94533
Medicare Provider Number
050367
Participating Start Date
7/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1704
Pharmacy Address
1501 HELEN POWER DRIVE
VACAVILLE, CA 95687
Pharmacy Comments
Contract Details
Approval Date
10/7/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
ART DENIO, CFO
(707) 646-3111
Contract Pharmacy Representative
Angela Hamil, 340B Implementation Analyst
(479) 227-3719
Signed By Date
10/7/2015
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