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MEDICINE SHOPPE PHARMACY
DSH050133 RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
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Covered Entity Details
Entity Name
RIDEOUT MEMORIAL HOSPITAL DBA Adventist Health and Rideout
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050133
Entity Address
726 4TH STREET
MARYSVILLE, CA 95901
Medicare Provider Number
050133
Participating Start Date
7/2/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MEDICINE SHOPPE PHARMACY
Pharmacy Address
812 FIFTH ST
MARYSVILLE, CA 95901
Pharmacy Comments
Contract Details
Approval Date
10/5/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2017
Ownership change
Contacts
Covered Entity Signing Official
Melissa Burns, COO
(530) 749-4542
Contract Pharmacy Representative
Medicine Shop
Luong Huynh, Manager
(530) 743-4629
Signed By Date
10/5/2016
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