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PARKHURST PHARMACY
CAH321308-00 CIBOLA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
CIBOLA GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321308-00
Entity Address
1016 ROOSEVELT AVE
GRANTS, NM 87020
Medicare Provider Number
321308
Participating Start Date
4/1/2021
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
PARKHURST PHARMACY
Pharmacy Address
1208 BONITA AVE
GRANTS, NM 87020
Pharmacy Comments
Contract Details
Approval Date
3/9/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
jim hermes, CFO
(505) 287-5302
Contract Pharmacy Representative
Parkhurst Pharmacy
Matt Munson, Owner
(505) 287-4641
Signed By Date
1/15/2021
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