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ALBERTSONS MARKET PHARMACY #682
CAH321306-00 LINCOLN COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
LINCOLN COUNTY MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321306-00
Entity Address
211 SUDDERTH
RUIDOSO, NM 88345
Medicare Provider Number
321306
Participating Start Date
1/1/2011
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
ALBERTSONS MARKET PHARMACY #682
Pharmacy Address
721 MECHEM DR. STE B
RUIDOSO, NM 88345
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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