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CITY MARKET PHARMACY #445
CAH061328-00 UPPER SAN JUAN HEALTH SERVICE DISTRICT
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Covered Entity Details
Entity Name
UPPER SAN JUAN HEALTH SERVICE DISTRICT
Subdivision Name
PAGOSA SPRINGS MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH061328-00
Entity Address
95 SOUTH PAGOSA BLVD
PAGOSA SPRINGS, CO 81147
Medicare Provider Number
061328
Participating Start Date
4/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
CITY MARKET PHARMACY #445
Pharmacy Address
165 COUNTRY CENTER DRIVE
PAGOSA SPRINGS, CO 81147
Pharmacy Comments
Contract Details
Approval Date
10/20/2011
Contract Begin Date
6/16/2011
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
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