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FORTIFY MARKET
DSH050301 ADVENTIST HEALTH UKIAH VALLEY
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Covered Entity Details
Entity Name
ADVENTIST HEALTH UKIAH VALLEY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050301
Entity Address
275 HOSPITAL DRIVE
UKIAH, CA 95482
Medicare Provider Number
050301
Participating Start Date
1/1/2007
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
FORTIFY MARKET
Pharmacy Address
ONE ADVENTIST HEALTH WAY
ROSEVILLE, CA 95661
Pharmacy Comments
Contract Details
Approval Date
10/13/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Warren Lee Tetz, Finance Officer
(707) 456-3001
Contract Pharmacy Representative
Adventist Health
Mandy Kazminy, Pharmacy Manager
(916) 406-0188
Signed By Date
10/13/2022
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