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KEITH'S PHARMACY LLC
CAH051309-01 JEROLD PHELPS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
JEROLD PHELPS COMMUNITY HOSPITAL
Subdivision Name
SOUTHERN HUMBOLDT COMMUNITY CLINIC
Type
Critical Access Hospital
340B ID
CAH051309-01
Entity Address
509 ELM STREET
GARBERVILLE, CA 95542
Medicare Provider Number
051309
Outpatient Facility Provider Number
Participating Start Date
7/1/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
KEITH'S PHARMACY LLC
Pharmacy Address
875 REDWOOD DRIVE
ATTN: PHARMACY
GARBERVILLE, CA 95542-3106
Pharmacy Comments
Contract Details
Approval Date
10/11/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/28/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Paul M. Eves, Chief Financial Officer
(707) 923-3921 Ext: 291
Contract Pharmacy Representative
LLC
Keith Lorang, Owner
(707) 923-2461
Signed By Date
10/11/2017
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