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WAL-MART PHARMACY 10-0966
CAH061327-00 Southwest Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061327-00
Entity Address
1311 North Mildred
Cortez, CO 81321
Medicare Provider Number
061327
Participating Start Date
4/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0966
Pharmacy Address
1835 EAST MAIN STREET
CORTEZ, CO 81321
Pharmacy Comments
Contract Details
Approval Date
9/26/2012
Contract Begin Date
9/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/31/2017
Agreement registered in error
Contacts
Covered Entity Signing Official
Kent Helwig, CEO
(970) 564-2146
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/4/2012
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