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PROVIDENCE HUMBOLDT HOME INFUSION
DSH050006 St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital
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Covered Entity Details
Entity Name
St. Joseph Health Northern California, LLC-DBA St. Joseph Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050006
Entity Address
2700 DOLBEER STREET
EUREKA, CA 95501
Medicare Provider Number
050006
Participating Start Date
4/1/2009
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
PROVIDENCE HUMBOLDT HOME INFUSION
Pharmacy Address
2612 HARRISON AVE
EUREKA, CA 95501
Pharmacy Comments
Contract Details
Approval Date
10/17/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Basil Saied, CFO
(707) 445-8121
Contract Pharmacy Representative
Providence St Joseph Hospital
Timothy Perlick, Pharmacy Director
(707) 445-8121 Ext: 6206
Signed By Date
10/17/2024
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