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NORTH LAKE MEDICAL PHARMACY #2
CAH051317-00 Adventist Health Clearlake Hospital, Inc.
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Covered Entity Details
Entity Name
Adventist Health Clearlake Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051317-00
Entity Address
15630 18th Ave - Hwy 53
Clearlake, CA 95422
Medicare Provider Number
051317
Participating Start Date
10/1/2011
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
NORTH LAKE MEDICAL PHARMACY #2
Pharmacy Address
347 LAKEPORT BOULEVARD
LAKEPORT, CA 95453-5412
Pharmacy Comments
1/11/10 ADDR UPDATE (WAS 355 LAKEPORT BLVD)
Contract Details
Approval Date
10/3/2012
Contract Begin Date
10/3/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2020
Ownership change
Contacts
Covered Entity Signing Official
Edward McDonald, CFO/COO
(707) 963-6217
Contract Pharmacy Representative
Bill Kearney, Owner
(707) 263-1328
Signed By Date
9/11/2012
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