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WELLBORN PHARMACY, INC.
CAH321302-00 DR. DAN C TRIGG MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DR. DAN C TRIGG MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321302-00
Entity Address
301 E MIEL DE LUNA
TUCUMCARI, NM 88401
Medicare Provider Number
321302
Participating Start Date
1/1/2011
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WELLBORN PHARMACY, INC.
Pharmacy Address
DBA MESA WINDS HEALTHMART PHARMACY
1923 S 1ST ST
TUCUMCARI, NM 88401
Pharmacy Comments
Contract Details
Approval Date
10/19/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DALE MAXWELL, SENIOR VP & CFO
(505) 923-5353
Contract Pharmacy Representative
Wellborn Pharmacy
Brian K. Wilson, President
(575) 461-2784
Signed By Date
10/19/2016
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