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CVS PHARMACY, INC.
DSH060126 Banner Fort Collins Medical Center
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Covered Entity Details
Entity Name
Banner Fort Collins Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060126
Entity Address
4700 Lady Moon Drive
Fort Collins, CO 80528
Medicare Provider Number
060126
Participating Start Date
10/1/2016
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
CVS PHARMACY, INC.
Pharmacy Address
CVS PHARMACY # 16536
1725 ROCKY MTN AVE
LOVELAND, CO 80538
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori L Sehrt, CFO - Northern Colorado
(970) 820-4004
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2020
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