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THRIFTY PAYLESS, INC.
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
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #6028
490 SOUTH MAIN STREET
FORT BRAGG, CA 95437
Pharmacy Comments
Contract Details
Approval Date
10/11/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/26/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bob S. Edwards, CEO
(707) 961-4611
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/11/2016
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