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WAL-MART PHARMACY 10-0869
CAH061308-00 Conejos County Hospital Corporation
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Covered Entity Details
Entity Name
Conejos County Hospital Corporation
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH061308-00
Entity Address
19021 US Hwy 285
La Jara, CO 81140
Medicare Provider Number
061308
Participating Start Date
1/1/2013
Last Recertification Date
8/21/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0869
Pharmacy Address
3333 CLARK STREET
ALAMOSA, CO 81101
Pharmacy Comments
Contract Details
Approval Date
4/15/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/25/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Henry Garvin, CEO
(719) 587-1205
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/15/2013
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