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ICARE RX LLC
DSH320004 CHRISTUS Southern New Mexico
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Covered Entity Details
Entity Name
CHRISTUS Southern New Mexico
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320004
Entity Address
2669 SCENIC DR
ALAMOGORDO, NM 88310-8734
Medicare Provider Number
320004
Participating Start Date
4/1/2015
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
ICARE RX LLC
Pharmacy Address
14447 COUNTRY WALK DR
MIAMI, FL 33186
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/8/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bashar Naser, CFO
(575) 443-7848 Ext: 5754437841
Contract Pharmacy Representative
Physicians Rx Pharmacy of Clinton
Chris Wakefield, Manager
(412) 357-5163
Signed By Date
10/15/2020
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