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WAL-MART PHARMACY 10-5997
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
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
7/17/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Johna Lederhouse, Controller
(970) 507-3760
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/17/2017
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