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PROCARE PHARMACY, L.L.C.
CAH031300-00 WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
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Covered Entity Details
Entity Name
WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031300-00
Entity Address
520 ROSE LANE
WICKENBURG, AZ 85390
Medicare Provider Number
031300
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PROCARE PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #2923
3250 HARDEN ST. EXT. SUITE #300
COLUMBIA, SC 29203
Pharmacy Comments
Contract Details
Approval Date
1/28/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/24/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jackie S Lundblad, CEO
(602) 321-8402
Contract Pharmacy Representative
CAREMARK LLC SPECIALTY
CHRISTIAN REID, SR. DIRECTOR 340B
(401) 770-2118
Signed By Date
1/28/2021
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