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WAL-MART PHARMACY 10-1334
CAH031314-00 Cobre Valley Regional Medical Center
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Covered Entity Details
Entity Name
Cobre Valley Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031314-00
Entity Address
5880 S. Hospital Drive
Globe, AZ 85501
Medicare Provider Number
031314
Participating Start Date
7/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1334
Pharmacy Address
100 SOUTH RAGUS ROAD
CLAYPOOL, AZ 85532
Pharmacy Comments
Contract Details
Approval Date
7/8/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James R. Childers, CFO
(928) 402-1123
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/8/2014
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