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WAL-MART PHARMACY 10-0906
DSH320038 REHOBOTH MCKINLEY CHRISTIAN HOSPITAL
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Covered Entity Details
Entity Name
REHOBOTH MCKINLEY CHRISTIAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320038
Entity Address
1901 RED ROCK DRIVE
GALLUP, NM 87301
Medicare Provider Number
320038
Participating Start Date
3/22/2022
Last Recertification Date
9/11/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0906
Pharmacy Address
1650WEST MALONEY AVENUE
GALLUP, NM 87301
Pharmacy Comments
Contract Details
Approval Date
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
William Kiefer, COO
(505) 863-7030
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/15/2014
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