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COMMCARE PHARMACY-FTL, LLC
CAH051320-00 BANNER LASSEN MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER LASSEN MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051320-00
Entity Address
1800 SPRING RIDGE DRIVE
SUSANVILLE, CA 96130
Medicare Provider Number
051320
Participating Start Date
9/20/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/18/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dave Kaubisch, Vice President of Finance
(602) 747-4556
Contract Pharmacy Representative
George Breznicki, Vice President and General Manager of Operations
(954) 332-6170
Signed By Date
10/12/2012
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