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THRIFTY PAYLESS, 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
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #6547
10570 TWIN CITIES ROAD
GALT, CA 95632
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul Ziegele, VP & Chief Financial Officer
(209) 339-7477
Contract Pharmacy Representative
Rite Aid
Alison Farrell, Vice President |Managed Care
(717) 975-5968
Signed By Date
10/17/2016
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