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WAL-MART PHARMACY 10-1273
CH08146V PEAK VISTA COMMUNITY HEALTH CENTERS
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Covered Entity Details
Entity Name
PEAK VISTA COMMUNITY HEALTH CENTERS
Subdivision Name
Health Center at Fountain
Type
HRSA-Funded Health Center
340B ID
CH08146V
Entity Address
350 Lyckman Dr
Fountain, CO 80817
Grant Number
H80CS00212
Participating Start Date
9/9/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1273
Pharmacy Address
6310 S. HWY 85-87
FOUNTAIN, CO 80817
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joel Tanaka, Chief Medical Officer
(719) 344-6530
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/13/2023
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