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RIVER CITY PHARMACY, INC.
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
RIVER CITY PHARMACY, INC.
Pharmacy Address
OPTION CARE
3301 C ST., STE 450
SACRAMENTO, CA 95816-3393
Pharmacy Comments
Contract Details
Approval Date
1/13/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/4/2023
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
Option Care
Jon Adair, Vice President, Health System Solutions
(847) 830-9996
Signed By Date
1/13/2016
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