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ARIZONA CVS STORES, L.L.C.
CAH031317-00 La Paz Regional Hospital
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Covered Entity Details
Entity Name
La Paz Regional Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031317-00
Entity Address
1200 W Mohave Road
Parker, AZ 85344
Medicare Provider Number
031317
Participating Start Date
4/1/2014
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
ARIZONA CVS STORES, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08802
131 W. RIVERSIDE DR.
PARKER, AZ 85344
Pharmacy Comments
Contract Details
Approval Date
7/1/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve T. Stewart, Chief Financial Officer
(928) 669-7400
Contract Pharmacy Representative
CVS Rx Services, Inc
Jordan Birnbaum, 340B Vendor Manager
(401) 770-2241
Signed By Date
7/1/2014
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