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OWENS PHARMACY #16
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
OWENS PHARMACY #16
Pharmacy Address
2920 A MAIN ST
SUSANVILLE, CA 96130
Pharmacy Comments
Contract Details
Approval Date
10/2/2013
Contract Begin Date
1/1/2014
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
Bob S. Edwards Jr., CEO BLMC
(530) 252-2234
Contract Pharmacy Representative
Jennie McCammon, Reimbursement and Compliance
(530) 245-1349
Signed By Date
10/2/2013
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