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CITY MARKET PHARMACY #22
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
CITY MARKET PHARMACY #22
Pharmacy Address
131 MARKET ST
ALAMOSA, CO 81101
Pharmacy Comments
09/12/2013 - Deleted duplicate Pharmacy per OPA instructions.
Contract Details
Approval Date
2/4/2011
Contract Begin Date
2/8/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
1/31/2011
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