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CITY MARKET STORE
CAH461302-00 Moab Valley Healthcare, Inc.
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Covered Entity Details
Entity Name
Moab Valley Healthcare, Inc.
Subdivision Name
dba Moab Regional Hospital
Type
Critical Access Hospital
340B ID
CAH461302-00
Entity Address
450 W. Williams Way
Moab, UT 84532
Medicare Provider Number
461302
Participating Start Date
4/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
CITY MARKET STORE
Pharmacy Address
PHARMACY DEPT
425 SOUTH MAIN
MOAB, UT 84532
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Craig Daniels, CFO
(435) 719-3503
Contract Pharmacy Representative
Kroger
Mike Puccini, New Business Development Manager
(513) 762-4672
Signed By Date
4/17/2017
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