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FORTIFY MARKET
DSH050336 Adventist Health Lodi Memorial
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Covered Entity Details
Entity Name
Adventist Health Lodi Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050336
Entity Address
975 S. FAIRMONT AVENUE
LODI, CA 95240
Medicare Provider Number
050336
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
FORTIFY MARKET
Pharmacy Address
ONE ADVENTIST HEALTH WAY
ROSEVILLE, CA 95661
Pharmacy Comments
Contract Details
Approval Date
4/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Katie Delmore, Finance Officer
(916) 406-1123
Contract Pharmacy Representative
Adventist Health
Mandy Kazminy, Pharmacy Manager
(916) 406-0188
Signed By Date
4/5/2023
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