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COMMUNITY PHARMACY - FOREST ROAD
SCH050335-00 ADVENTIST HEALTH SONORA
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Covered Entity Details
Entity Name
ADVENTIST HEALTH SONORA
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH050335-00
Entity Address
1000 GREENLEY ROAD
SONORA, CA 95370
Medicare Provider Number
050335
Participating Start Date
7/1/2024
Last Recertification Date
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
COMMUNITY PHARMACY - FOREST ROAD
Pharmacy Address
ADVENTIST HEALTH SONORA
220 W STOCKTON ST
SONORA, CA 95370
Pharmacy Comments
Contract Details
Approval Date
5/3/2012
Contract Begin Date
5/3/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeffrey Dean Eller, President/CEO
(209) 536-5012
Contract Pharmacy Representative
Tari Brink, Pharmacy Operations Coordinator
(209) 536-3698
Signed By Date
3/28/2012
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