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IONE PHARMACY
DSH050336 Adventist Health Lodi Memorial
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Covered Entity Details
Entity Name
Adventist Health Lodi Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050336
Entity Address
975 S. FAIRMONT AVENUE
LODI, CA 95240
Medicare Provider Number
050336
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
IONE PHARMACY
Pharmacy Address
307 PRESTON AVE
P.O.BOX 1025
IONE, CA 95640
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/24/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Terry Deak, VP & Chief Financial Officer
(209) 339-7898
Contract Pharmacy Representative
Carolyn Stremfel, Pharmacist/ Owner
(209) 274-2432
Signed By Date
10/14/2015
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