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RALEY'S PHARMACY #113
CAH051328-00 TAHOE FOREST HOSPITAL
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Covered Entity Details
Entity Name
TAHOE FOREST HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051328-00
Entity Address
10121 PINE AVENUE
TRUCKEE, CA 96161
Medicare Provider Number
051328
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
RALEY'S PHARMACY #113
Pharmacy Address
930 TAHOE BLVD
INCLINE VILLAGE, NV 89451
Pharmacy Comments
Contract Details
Approval Date
7/18/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/11/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
CRYSTAL BETTS, CHIEF FINANCIAL OFFICER
(530) 582-6656
Contract Pharmacy Representative
Raley's
Cindy Fong, Director of Pharmacy
(916) 373-6411
Signed By Date
7/18/2023
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