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WALMART PHARMACY 10-4491
DSH060023 St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
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Covered Entity Details
Entity Name
St. Mary's Hospital & Medical Center, Inc dba Intermountain Health St. Mary's Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060023
Entity Address
2635 N. 7TH STREET
GRAND JUNCTION, CO 81501
Medicare Provider Number
060023
Participating Start Date
10/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4491
Pharmacy Address
541 WARRIOR WAY
GRAND JUNCTION, CO 81504
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/18/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Terri Chinn, CFO
(970) 298-2020
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
10/16/2019
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