Contract Pharmacy Details

WAL-MART PHARMACY 10-3423
DSH320002 ST. VINCENT HOSPITAL

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

WAL-MART PHARMACY 10-3423

Pharmacy Address

5701 HERRERA DRIVE
SANTA FE, NM 87507

Pharmacy Comments

Contract Details

Approval Date

1/2/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Bruce Tassin, CEO
(505) 913-5201

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

1/2/2014

340B Drug Pricing Program Database