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WAL-MART PHARMACY 10-4201
DSH320021 PRESBYTERIAN HOSPITAL
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Covered Entity Details
Entity Name
PRESBYTERIAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320021
Entity Address
1100 CENTRAL AVENUE SE
ALBUQUERQUE, NM 87106
Medicare Provider Number
320021
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4201
Pharmacy Address
66 STATE ROUTE #344
EDGEWOOD, NM 87015
Pharmacy Comments
Contract Details
Approval Date
4/7/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DALE MAXWELL, SENIOR VP & CFO
(505) 923-5353
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/7/2014
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