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SMITHS FOOD & DRUG CENTERS
DSH320002 ST. VINCENT HOSPITAL
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Covered Entity Details
Entity Name
ST. VINCENT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320002
Entity Address
455 ST. MICHAELS DRIVE
SANTA FE, NM 87505
Medicare Provider Number
320002
Participating Start Date
1/1/2014
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
SMITHS FOOD & DRUG CENTERS
Pharmacy Address
SMITH'S PHARMACY #461
2308 CERRILLOS ROAD
SANTA FE, NM 87505
Pharmacy Comments
Contract Details
Approval Date
1/2/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/18/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bruce Tassin, CEO
(505) 913-5201
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
1/2/2014
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