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WAL-MART PHARMACY 10-2656
CH063450 PRESBYTERIAN MEDICAL SERVICES, INC.
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Covered Entity Details
Entity Name
PRESBYTERIAN MEDICAL SERVICES, INC.
Subdivision Name
PRESBYTERIAN MEDICAL SERVICES
Type
HRSA-Funded Health Center
340B ID
CH063450
Entity Address
1422 PASEO DE PERALTA
SANTA FE, NM 87501-4391
Grant Number
H80CS00205
Participating Start Date
12/1/1992
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2656
Pharmacy Address
1610 N RIVERSIDE DRIVE
ESPANOLA, NM 87532
Pharmacy Comments
Contract Details
Approval Date
7/20/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven C. Hansen, CEO
(505) 982-5565 Ext: 3470
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/20/2017
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