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RALEY'S PHARMACY #328
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
RALEY'S PHARMACY #328
Pharmacy Address
1315 NORTH STATE STREET
UKIAH, CA 95482
Pharmacy Comments
Contract Details
Approval Date
8/17/2012
Contract Begin Date
8/17/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brandon Parker, CFO
(707) 467-5270
Contract Pharmacy Representative
Raley's
Flint Pendergraft, Vice President, Pharmacy & Healthy Lifestyle Initiatives
(916) 373-6146
Signed By Date
7/17/2012
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