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LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050174 ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
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Covered Entity Details
Entity Name
ST Joseph Health Northern California LLC-DBA Santa Rosa Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050174
Entity Address
1165 MONTGOMERY DRIVE
Santa Rosa, CA 95405
Medicare Provider Number
050174
Participating Start Date
4/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09872
6877 SEBASTOPOL AVENUE
SEBASTOPOL, CA 95472
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
Christian Reid, 340B Program Director
(401) 770-2118
Signed By Date
7/8/2015
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