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SMITH'S DRUG #409
DSH320005 SAN JUAN REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SAN JUAN REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320005
Entity Address
801 W. MAPLE
FARMINGTON, NM 87401
Medicare Provider Number
320005
Participating Start Date
9/1/2008
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
SMITH'S DRUG #409
Pharmacy Address
SMITH'S FOOD KING NO 1
600 EAST 20TH ST
FARMINGTON, NM 87401
Pharmacy Comments
Contract Details
Approval Date
7/28/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/4/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Karen S. Miller, CFO
(505) 609-6114
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
7/28/2015
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