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PINON FAMILY PHARMACY
DSH320005 SAN JUAN REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN JUAN REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320005
Entity Address
801 W. MAPLE
FARMINGTON, NM 87401
Medicare Provider Number
320005
Participating Start Date
9/1/2008
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
PINON FAMILY PHARMACY
Pharmacy Address
2300 E 30TH ST STE B-101
FARMINGTON, NM 87401
Pharmacy Comments
Contract Details
Approval Date
10/19/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ryan Manning, Director of Finance
(505) 609-6084
Contract Pharmacy Representative
Pinon Family Pharmacy
Craig Burgess, Owner/PIC
(505) 327-4826
Signed By Date
10/19/2023
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