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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Konnie Martin, CEO
(719) 587-1202
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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