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WAL-MART PHARMACY 10-2652
CAH321308-00 CIBOLA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
CIBOLA GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH321308-00
Entity Address
1016 ROOSEVELT AVE
GRANTS, NM 87020
Medicare Provider Number
321308
Participating Start Date
4/1/2021
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2652
Pharmacy Address
1000 ROBERTS DRIVE
GRANTS, NM 87020
Pharmacy Comments
Contract Details
Approval Date
10/3/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
J. F. Rimel Jr., Asst. Admin. & CFO
(505) 287-5300
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/3/2014
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