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SMITH'S PHARMACY #463
DSH320089 UNM SANDOVAL REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
UNM SANDOVAL REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320089
Entity Address
3001 BROADMOOR BLVD NE
RIO RANCHO, NM 87144
Medicare Provider Number
320089
Participating Start Date
4/1/2016
Last Recertification Date
8/17/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
SMITH'S PHARMACY #463
Pharmacy Address
4800 MCMAHON BLVD. NW
ALBUQUERQUE, NM 87114-5010
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/17/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jamie Silva-Steele, President and CEO
(505) 994-7430
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
7/8/2020
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