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WAL-MART PHARMACY 10-1364
CAH031317-00 La Paz Regional Hospital
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Covered Entity Details
Entity Name
La Paz Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031317-00
Entity Address
1200 W Mohave Road
Parker, AZ 85344
Medicare Provider Number
031317
Participating Start Date
4/1/2014
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1364
Pharmacy Address
5695 HWY 95 NORTH
LAKE HAVASU CITY, AZ 86404
Pharmacy Comments
Contract Details
Approval Date
4/2/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kevin M Brown, CEO
(928) 669-7300
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/2/2020
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