Contract Pharmacy Details

THRIFTY PAYLESS, INC.
CAH051319-00 DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA

Covered Entity Details

Entity Name

DIGNITY HEALTH D/B/A MERCY MEDICAL CENTER MT. SHASTA

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH051319-00

Entity Address

914 PINE STREET.
MOUNT SHASTA, CA 96067

Medicare Provider Number

051319

Participating Start Date

9/8/2010

Last Recertification Date

8/15/2024

Pharmacy Details

Pharmacy Name

THRIFTY PAYLESS, INC.

Pharmacy Address

RITE AID #6103
310 WEST LAKE STREET
MOUNT SHASTA, CA 96067

Pharmacy Comments

Contract Details

Approval Date

1/14/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Kenneth Platou, President
(530) 926-9378

Contract Pharmacy Representative

Rite Aid
Tammy Royer, Group Vice President, Managed Care
(717) 730-8217

Signed By Date

1/14/2014

340B Drug Pricing Program Database