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COMMUNITY PHARMACY - FOREST ROAD
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
COMMUNITY PHARMACY - FOREST ROAD
Pharmacy Address
ADVENTIST HEALTH SONORA
220 W STOCKTON ST
SONORA, CA 95370
Pharmacy Comments
Contract Details
Approval Date
4/6/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Heidar Thordarson, VP Finance / CFO
(530) 751-4012
Contract Pharmacy Representative
Adventist Health
Mandy Kazminy, Pharmacy Manager
(916) 406-0188
Signed By Date
4/6/2023
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