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GREEN'S FORTUNA PHARMACY
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
GREEN'S FORTUNA PHARMACY
Pharmacy Address
1058 MAIN ST
FORTUNA, CA 95540
Pharmacy Comments
Contract Details
Approval Date
2/11/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joe Rogers, Chief Operating Officer
(707) 725-3361 Ext: 4351
Contract Pharmacy Representative
Green's Fortuna Pharmacy
Robert Johnson, President
(707) 499-2336
Signed By Date
1/7/2013
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