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KMART PHARMACY #4819
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
KMART PHARMACY #4819
Pharmacy Address
2019 S. MAIN
LAKEPORT, CA 95453
Pharmacy Comments
Contract Details
Approval Date
10/19/2012
Contract Begin Date
10/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/6/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Edward McDonald, CFO/COO
(707) 963-6217
Contract Pharmacy Representative
Ghassan Hourani, VP/GMM Pharmacy Administration
(847) 286-3382
Signed By Date
9/14/2012
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