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WALMART PHARMACY 10-5169
DSH060008 SAN LUIS VALLEY REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN LUIS VALLEY REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060008
Entity Address
106 BLANCA AVE
ALAMOSA, CO 81101
Medicare Provider Number
060008
Participating Start Date
10/1/2004
Last Recertification Date
8/27/2024
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
7/19/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Konnie Martin, CEO
(719) 587-1202
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/19/2023
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