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FLAGSTAFF PHARMACY
SCH030007-00 VERDE VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
VERDE VALLEY MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030007-00
Entity Address
269 SOUTH CANDY LANE
COTTONWOOD, AZ 86326
Medicare Provider Number
030007
Participating Start Date
9/30/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
FLAGSTAFF PHARMACY
Pharmacy Address
77 W FOREST AVE STE 104
FLAGSTAFF, AZ 86001
Pharmacy Comments
Contract Details
Approval Date
10/3/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/24/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Treasure, VP/Finance - CFO
(928) 773-2340
Contract Pharmacy Representative
Northern Arizona Healthcare
RICHARD MENDRIBIL, SYSTEM DIRECTOR OF PHARMACY
(928) 773-2117
Signed By Date
10/3/2016
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