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UNITED SUPERMARKETS, LLC
DSH320011 ESPANOLA HOSPITAL
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Covered Entity Details
Entity Name
ESPANOLA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320011
Entity Address
1010 SPRUCE STREET
ESPANOLA, NM 87532
Medicare Provider Number
320011
Participating Start Date
4/1/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
UNITED SUPERMARKETS, LLC
Pharmacy Address
ALBERTSONS MARKET PHARMACY #920
710A PASEO DEL PUEBLO SUR
TAOS, NM 87571
Pharmacy Comments
Contract Details
Approval Date
7/10/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/8/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Roger Larsen, Sr. Vice President and Chief Financial Officer
(505) 923-5338
Contract Pharmacy Representative
Safeway
charles Hanson, 340B program manager
(208) 395-6304
Signed By Date
7/10/2019
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