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WAL-MART PHARMACY 10-5315
DSH320038 REHOBOTH MCKINLEY CHRISTIAN HOSPITAL
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Covered Entity Details
Entity Name
REHOBOTH MCKINLEY CHRISTIAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320038
Entity Address
1901 RED ROCK DRIVE
GALLUP, NM 87301
Medicare Provider Number
320038
Participating Start Date
3/22/2022
Last Recertification Date
9/11/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
William Kiefer, COO
(505) 863-7030
Contract Pharmacy Representative
REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Mary D. Bever, CFO
(505) 863-7170
Signed By Date
7/17/2018
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