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WAL-MART PHARMACY 10-5330
DSH030014 HONORHEALTH JOHN C. LINCOLN MED CTR
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Covered Entity Details
Entity Name
HONORHEALTH JOHN C. LINCOLN MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030014
Entity Address
250 E Dunlap Ave
Phoenix, AZ 85020
Medicare Provider Number
030014
Participating Start Date
7/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5330
Pharmacy Address
6145 NORTH 35TH AVENUE
PHOENIX, AZ 85017
Pharmacy Comments
Contract Details
Approval Date
7/15/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/26/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Maggi Griffin, CEO
(602) 331-5862
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/15/2015
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