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ARIZONA CVS STORES, L.L.C.
SCH030055-00 Kingman Regional Medical Center
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Covered Entity Details
Entity Name
Kingman Regional Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH030055-00
Entity Address
3269 Stockton Hill Road
Kingman, AZ 86409
Medicare Provider Number
030055
Participating Start Date
7/1/2013
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
ARIZONA CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08977
3501 STOCKTON HILL RD.
KINGMAN, AZ 86409
Pharmacy Comments
Contract Details
Approval Date
7/10/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Blanchard, CFO
(928) 681-8668
Contract Pharmacy Representative
CVS
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
7/1/2013
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