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WAL-MART PHARMACY 10-5232
CAH061317-00 Grand River Hospital District
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Covered Entity Details
Entity Name
Grand River Hospital District
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061317-00
Entity Address
501 Airport Rd
Rifle, CO 81650
Medicare Provider Number
061317
Participating Start Date
10/1/2012
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5232
Pharmacy Address
1000 AIRPORT RD
RIFLE, CO 81650
Pharmacy Comments
Contract Details
Approval Date
4/25/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Coombs, CEO
(970) 625-6405
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/25/2014
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