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WAL-MART PHARMACY 10-1019
SCH060016-00 ST THOMAS MORE HOSPITAL
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Covered Entity Details
Entity Name
ST THOMAS MORE HOSPITAL
Subdivision Name
Centura Health
Type
Sole Community Hospital
340B ID
SCH060016-00
Entity Address
1338 PHAY AVE
CANON CITY, CO 81212
Medicare Provider Number
060016
Participating Start Date
10/1/2014
Last Recertification Date
9/7/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1019
Pharmacy Address
3105 HWY 50 EAST
CANON CITY, CO 81212
Pharmacy Comments
Contract Details
Approval Date
7/14/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/27/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gwyneth Howard, CFO
(719) 285-2264
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/14/2015
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