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SISKIYOU PHARMACY SERVICES
CAH051316-02 Fairchild Medical Center
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Covered Entity Details
Entity Name
Fairchild Medical Center
Subdivision Name
Fairchild Medical Clinic
Type
Critical Access Hospital
340B ID
CAH051316-02
Entity Address
475 Bruce St
Yreka, CA 96097
Medicare Provider Number
051316
Outpatient Facility Provider Number
058634
Participating Start Date
7/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
SISKIYOU PHARMACY SERVICES
Pharmacy Address
DBA MEDICAL CENTER PHARMACY
742 S. MAIN STREET
YREKA, CA 96097
Pharmacy Comments
Contract Details
Approval Date
7/1/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kelly Martin, CFO
(530) 841-6235
Contract Pharmacy Representative
Candice Amens, Owner
(530) 842-4301
Signed By Date
7/1/2013
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