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WAL-MART PHARMACY 10-1903
SCH050133-00 RIDEOUT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
RIDEOUT MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH050133-00
Entity Address
726 4TH STREET
MARYSVILLE, CA 95901
Medicare Provider Number
050133
Participating Start Date
4/1/2018
Last Recertification Date
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1903
Pharmacy Address
1150 HARTER ROAD
YUBA CITY, CA 95993
Pharmacy Comments
Contract Details
Approval Date
1/25/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Diane Moon, CFO
(530) 751-4260
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, Vice President
(800) 939-2022
Signed By Date
1/16/2018
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