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WALMART PHARMACY 10-5169
CAH061321-00 Trinidad Area Health Association DBA Mount San Rafael Hospital
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Covered Entity Details
Entity Name
Trinidad Area Health Association DBA Mount San Rafael Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061321-00
Entity Address
410 Benedicta Avenue
Trinidad, CO 81082-2005
Medicare Provider Number
061321
Participating Start Date
7/1/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
5/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Calvin Carey, CFO
(719) 846-8042
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr Director Payer Relations
(479) 739-1973
Signed By Date
5/5/2023
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