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WAL-MART PHARMACY 10-0986
CAH061319-00 ST. VINCENT GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061319-00
Entity Address
822 WEST 4TH ST.
LEADVILLE, CO 80461
Medicare Provider Number
061319
Participating Start Date
10/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0986
Pharmacy Address
840 SUMMIT BLVD.
P.O. BOX 4220
FRISCO, CO 80443
Pharmacy Comments
Contract Details
Approval Date
10/10/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andrew Dreesen, CEO
(719) 486-7161
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/10/2023
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