Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
DSH050336 Adventist Health Lodi Memorial

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

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03022
1063 C ST
GALT, CA 95632

Pharmacy Comments

Contract Details

Approval Date

4/16/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Paul Ziegele, VP & Chief Financial Officer
(209) 339-7477

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/16/2018

340B Drug Pricing Program Database