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NOWELL PHARMACY, LLC
CAH321305-03 NOR-LEA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
NOR-LEA GENERAL HOSPITAL
Subdivision Name
TATUM CLINIC
Type
Critical Access Hospital
340B ID
CAH321305-03
Entity Address
204 N. MAIN STREET
TATUM, NM 88267
Medicare Provider Number
321305
Outpatient Facility Provider Number
323984
Participating Start Date
9/24/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
NOWELL PHARMACY, LLC
Pharmacy Address
122 W ADAMS AVE
LOVINGTON, NM 88260-4010
Pharmacy Comments
Contract Details
Approval Date
4/16/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Shaw, CEO
(575) 396-6611 Ext: 1102
Contract Pharmacy Representative
JOANN DOMZALSKI, OWNER
(575) 396-4242
Signed By Date
4/16/2013
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