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WAL-MART PHARMACY 10-1846
CAH031312-00 Bisbee Hospital Association dba Copper Queen Community Hospital
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Covered Entity Details
Entity Name
Bisbee Hospital Association dba Copper Queen Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031312-00
Entity Address
101 Cole Ave
Bisbee, AZ 85603
Medicare Provider Number
031312
Participating Start Date
4/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1846
Pharmacy Address
199 WEST 5TH STREET
DOUGLAS, AZ 85607
Pharmacy Comments
Contract Details
Approval Date
1/7/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Moore, CFO
(520) 432-6450
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/7/2014
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