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LAKE PHARMACY
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
LAKE PHARMACY
Pharmacy Address
LAKE PHARMACY
15230 LAKESHORE DR
CLEARLAKE, CA 95422-6376
Pharmacy Comments
Contract Details
Approval Date
4/12/2017
Contract Begin Date
4/26/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CARLTON Edward JACOBSON, CFO
(707) 995-5824
Contract Pharmacy Representative
Lake Pharmacy
Tim Nguyen, Owner
(707) 994-3141
Signed By Date
4/12/2017
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