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WAL-MART PHARMACY 10-1230
DSH030062 SUMMIT HEALTHCARE ASSOCIATION DBA SUMMIT HEALTHCARE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
SUMMIT HEALTHCARE ASSOCIATION DBA SUMMIT HEALTHCARE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030062
Entity Address
2200 EAST SHOW LOW LAKE ROAD
SHOW LOW, AZ 85901
Medicare Provider Number
030062
Participating Start Date
1/1/2009
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1230
Pharmacy Address
5401 S. WHITE MOUNTAIN ROAD
SHOW LOW, AZ 85901
Pharmacy Comments
Contract Details
Approval Date
4/4/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kurt R. Loveless, CFO
(928) 537-6375
Contract Pharmacy Representative
Loren Wright, Pharmacist In Charge
(928) 537-3010
Signed By Date
4/4/2014
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