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LUCKY PHARMACY #730
DSH050013 St. Helena Hospital, DBA Adventist Health St. Helena
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Covered Entity Details
Entity Name
St. Helena Hospital, DBA Adventist Health St. Helena
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050013
Entity Address
10 WOODLAND ROAD
ST. HELENA, CA 94574
Medicare Provider Number
050013
Participating Start Date
4/1/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
LUCKY PHARMACY #730
Pharmacy Address
2355 CALIFORNIA BLVD
NAPA, CA 94559
Pharmacy Comments
Contract Details
Approval Date
10/1/2012
Contract Begin Date
10/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Edward McDonald, CFO/COO
(707) 963-6217
Contract Pharmacy Representative
Robert Vaughan, Senior Director of Pharmacy Operations
(209) 574-6220
Signed By Date
9/7/2012
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