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ARIZONA CVS STORES, L.L.C.
DSH030023 FLAGSTAFF MEDICAL CENTER
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Covered Entity Details
Entity Name
FLAGSTAFF MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030023
Entity Address
1200 NORTH BEAVER
FLAGSTAFF, AZ 86001
Medicare Provider Number
030023
Participating Start Date
7/1/2009
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
ARIZONA CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09231
3506 EAST ROUTE 66
FLAGSTAFF, AZ 86004
Pharmacy Comments
Contract Details
Approval Date
7/16/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/11/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Clifford F Loader, Chief Financial Officer
(928) 773-2282
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/16/2020
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