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WHITE MOUNTAIN PHARMACY
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
WHITE MOUNTAIN PHARMACY
Pharmacy Address
N & R BRYCE ENTERPRISES LLC
4461 S WHITE MOUNTAIN RD STE E1
SHOW LOW, AZ 85901-7782
Pharmacy Comments
Contract Details
Approval Date
7/16/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kurt R. Loveless, CFO
(928) 537-6375
Contract Pharmacy Representative
Nickalaus D. Bryce, Pharmacist In Charge
(928) 536-2044
Signed By Date
7/16/2014
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