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WAL-MART PHARMACY 10-5315
CAH061321-00 Trinidad Area Health Association DBA Mount San Rafael Hospital
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Covered Entity Details
Entity Name
Trinidad Area Health Association DBA Mount San Rafael Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061321-00
Entity Address
410 Benedicta Avenue
Trinidad, CO 81082-2005
Medicare Provider Number
061321
Participating Start Date
7/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Calvin Carey, CFO
(719) 846-8042
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/15/2020
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