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WAL-MART PHARMACY 10-2672
CAH061323-00 PROWERS MEDICAL CENTER
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Covered Entity Details
Entity Name
PROWERS MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061323-00
Entity Address
401 KENDALL DRIVE
LAMAR, CO 81052
Medicare Provider Number
061323
Participating Start Date
1/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2672
Pharmacy Address
1432 EAST OLIVE
LAMAR, CO 81052
Pharmacy Comments
Contract Details
Approval Date
7/1/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Audrey Kane, CFO
(719) 336-6753
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/1/2015
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