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MONTE VISTA MEDICAL CLINIC PHARMACY
CAH061301-00 RIO GRANDE HOSPITAL
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Covered Entity Details
Entity Name
RIO GRANDE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061301-00
Entity Address
310 COUNTY ROAD 14
DEL NORTE, CO 81132
Medicare Provider Number
061301
Participating Start Date
9/9/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
MONTE VISTA MEDICAL CLINIC PHARMACY
Pharmacy Address
1033 2ND AVE
MONTE VISTA, CO 81144
Pharmacy Comments
Contract Details
Approval Date
1/3/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ARLENE HARMS, CEO
(719) 657-4104
Contract Pharmacy Representative
Rio Grande Hospital
Nellie Edelen, Pharmacy Manager
(719) 657-4097
Signed By Date
1/3/2017
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