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EL DORADO DRUG STORE
DSH050167 SAN JOAQUIN GENERAL HOSPITAL
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Covered Entity Details
Entity Name
SAN JOAQUIN GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050167
Entity Address
500 WEST HOSPITAL ROAD
FRENCH CAMP, CA 95231
Medicare Provider Number
050167
Participating Start Date
1/1/1999
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
EL DORADO DRUG STORE
Pharmacy Address
2005 S MARIPOSA RD
STOCKTON, CA 95205
Pharmacy Comments
Contract Details
Approval Date
10/4/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
RICHARD ALDRED, SENIOR DEPUTY DIRECTOR
(209) 468-6600
Contract Pharmacy Representative
El Dorado Drug
JEFFERY BENNET, MANAGER
(209) 464-7722
Signed By Date
10/4/2013
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