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WALGREEN ARIZONA DRUG CO.
DSH320005 SAN JUAN REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN JUAN REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320005
Entity Address
801 W. MAPLE
FARMINGTON, NM 87401
Medicare Provider Number
320005
Participating Start Date
9/1/2008
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WALGREEN ARIZONA DRUG CO.
Pharmacy Address
WALGREENS CENTRAL FILL #21372
120 N 83RD AVE
STE 200
TOLLESON, AZ 85353
Pharmacy Comments
Contract Details
Approval Date
7/6/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ryan Manning, Director of Finance
(505) 609-6084
Contract Pharmacy Representative
San Juan Regional Medical Center
Mark Winters, Pharmacy Manager
(505) 609-2484
Signed By Date
7/6/2021
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