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WAL-MART PHARMACY 10-0986
FQHCLA324B SUMMIT COMMUNITY CARE CLINIC
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Covered Entity Details
Entity Name
SUMMIT COMMUNITY CARE CLINIC
Subdivision Name
Summit High School
Type
Health Center Program Look-Alike
340B ID
FQHCLA324B
Entity Address
16210 Highway 9
Breckenridge, CO 80424
Grant Number
LALCS00138
Participating Start Date
10/1/2014
Last Recertification Date
2/19/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0986
Pharmacy Address
840 SUMMIT BLVD.
P.O. BOX 4220
FRISCO, CO 80443
Pharmacy Comments
Contract Details
Approval Date
1/15/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sarah E. Vaine, CEO
(970) 668-4049
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/15/2015
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