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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050136 NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
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Covered Entity Details
Entity Name
NorCal HealthConnect LLC, DBA Petaluma Valley Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050136
Entity Address
400 N. MCDOWELL BLVD
PETALUMA, CA 94954
Medicare Provider Number
050136
Participating Start Date
4/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09480
365 E WASHINGTON ST
PETALUMA, CA 94952
Pharmacy Comments
Contract Details
Approval Date
7/8/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/2/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mich Riccioni, CFO
(707) 445-8121 Ext: 7491
Contract Pharmacy Representative
CVS
Christian Reid, 340B Program Director, CVS Pharmacy
(401) 770-2118
Signed By Date
7/8/2015
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