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WAL-MART PHARMACY 10-1384
DSH060036 Arkansas Valley Regional Medical Center
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Covered Entity Details
Entity Name
Arkansas Valley Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060036
Entity Address
1100 Carson Avenue
La Junta, CO 81050
Medicare Provider Number
060036
Participating Start Date
7/1/2014
Last Recertification Date
8/18/2016
Entity Termination Date
7/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1384
Pharmacy Address
6 CONLEY ROAD
LA JUNTA, CO 81050
Pharmacy Comments
Contract Details
Approval Date
10/7/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lynn Crowell, Chief Executive Officer
(719) 383-6000
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/7/2014
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