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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/28/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Konnie Martin, CEO
(719) 587-1202
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/28/2017
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