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WAL-MART PHARMACY 10-1600
CAH051333-00 Ridgecrest Regional Hospital
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Covered Entity Details
Entity Name
Ridgecrest Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH051333-00
Entity Address
1081 N. China Lake Blvd.
Ridgecrest, CA 93555
Medicare Provider Number
051333
Participating Start Date
10/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1600
Pharmacy Address
201 EAST BOWMAN RD.
RIDGECREST, CA 93555
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Suver, CEO
(760) 499-3902
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/8/2014
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