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MENDOCINO COAST PHARMACY
CAH051325-00 ADVENTIST HEALTH MENDOCINO COAST
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Covered Entity Details
Entity Name
ADVENTIST HEALTH MENDOCINO COAST
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051325-00
Entity Address
700 RIVER DRIVE
FORT BRAGG, CA 95437
Medicare Provider Number
051325
Participating Start Date
8/11/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MENDOCINO COAST PHARMACY
Pharmacy Address
350 CYPRESS ST
FORT BRAGG, CA 95437-5408
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wayne C. Allen, CEO
(707) 961-4630
Contract Pharmacy Representative
Mendocino Village Pharmacy
Kelly Brodetsky, Owner
(707) 962-0800
Signed By Date
4/14/2014
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