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WAL-MART PHARMACY 10-1442
CAH031304-00 Page Hospital
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Covered Entity Details
Entity Name
Page Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031304-00
Entity Address
501 North Navajo
Page, AZ 86040
Medicare Provider Number
031304
Participating Start Date
4/1/2012
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1442
Pharmacy Address
1017 WEST HAUL ROAD
PAGE, AZ 86040
Pharmacy Comments
Contract Details
Approval Date
9/10/2012
Contract Begin Date
9/10/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dennis Dahlen, Senior Vice President, CFO
(602) 747-4727
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/9/2012
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