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LA JARA PHARMACEUTICAL CENTER
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
LA JARA PHARMACEUTICAL CENTER
Pharmacy Address
LA JARA PHARMACY
412 MAIN STREET
P.O. BOX 609
LA JARA, CO 81140
Pharmacy Comments
Contract Details
Approval Date
10/8/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Konnie Martin, CEO
(719) 587-1202
Contract Pharmacy Representative
Joseph T. Valdez, Owner/Partner
(719) 274-5109
Signed By Date
10/8/2013
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